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Introduction

Given evidence of potentially severe unintended consequences upon system/ technology implementation in health care settings, adequate analysis of workflow and exploration of potential unintended consequences is essential prior to implementation of any system or technology. 1 However, standard analysis is limited to observation of pre-implementation workflow. Additionally, systems and technologies chosen for broad implementation in tertiary care facilities may not fit specialized settings such as emergency departments. Agent-based modeling enables exploration of system behavior over a broad range of parameters, and so may provide crucial pre-implementation insight into the impact of a new system/technology on workflow and/or outcomes. The purpose of this study was two-fold: (1) to develop an agent-based model simulating patient flow and provider workflow in an emergency department setting, relative to the number and placement of terminals in an emergency department, and (2) to characterize the behavior of the emergency care delivery system relative to the number and placement of a workstationsover a wide range of parameters.

Background and Significance

Adequate analysis and consideration of workflow in relation to new systems/ technologies is essential in health care settings. A 2005 study by Han et al found increased mortality after implementation of CPOE (computerized provider order entry) in the Pittsburgh Children’s Hospital emergency department and PICU (pediatric intensive care unit). 1 A subsequent study by DelBaccoro and colleagues yielded contradictory findings, showing no change in mortality rate in a PICU. 2 Experts attributed these contradictory findings to substantial qualitative differences in the process of CPOE implementation in the two settings. 3 In the case of Pittsburgh Children’s Hospital, multiple unintended consequences resulting from inadequate pre-implementation analysis and planning led to delays in care. One of the unintended consequences was a severe mismatch between workflow imposed by CPOE and existent workflow in the care setting. In essence, the unique characteristics of workflow were not adequately considered relative to the system/ technology, prior to implementation.

In the Han et al study, the emergency department encountered multiple unintended consequences of CPOE implementation. Unique characteristics of emergency department settings, relative to most other care settings in the hospital, include high patient acuity, rapid turnover of patients, and high intensity of nursing and medical care. Unexpected alterations in workflow related to the introduction of technology/ systems in these settings have demonstrated potential to adversely affect patient outcomes. 1 Additionally, expected alterations in workflow caused by the introduction of technologies/systems may have more severe effects in the emergency department, due to high patient acuity coupled with the necessity of rapid, highly coordinated care. Clearly, a careful consideration of potential unintended consequences in the specialized emergency department setting is desirable pre-implementation, in order to inform design and implementation processes.

One basic design/ implementation decision, particularly in the case of electronic health record (EHR) and CPOE systems, is the number and placement of computer terminals. Health care providers, generally nurses or physicians, must physically access a terminal to access information (i.e. health history, recent vital signs) or to input information (i.e. documentation, orders). Poissant and colleagues (2005) reviewed studies of time efficiency in EHR documentation. Their comparisons of PDA, bedside, and central terminal placement evidence no clear advantage to any particular distribution of terminals. 4 The comparison was complicated by the time point at which data was collected in the individual studies. Some studies collected data during the first three months post-implementation, when there is a generally observed increase in documentation time, while others collected data at later timepoints. Also, the studies differ dramatically in setting. As a result, there is no clear empiric evidence to guide optimal number and placement of terminals.

Agent-based modeling. Agent-based modeling enables analysis of what-if? Scenarios, by linking key variables with outcomes. By varying parameters over a wide range, we are able to characterize the overall behavior of a complex system, in this case, workflow in relation to the number and placement of workstations in an emergency department. (Heather is going to write/ develop this paragraph).

Methods

Results

Discussion

References

1. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. Dec 2005;116(6):1506-1512.
2. Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit. Pediatrics. Jul 2006;118(1):290-295.
3. Ammenwerth E, Talmon J, Ash JS, et al. Impact of CPOE on mortality rates--contradictory findings, important messages. Methods Inf Med. 2006;45(6):586-593.
4. Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. Sep-Oct 2005;12(5):505-516.

--Mpoynton 12:05, 21 June 2007 (MDT)