First medical contact and physicians’ opinion after the implementation of an electronic record system

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1235-1240

Brief Report

First medical contact and physicians’ opinion after the implementation of an electronic record system

Pierre-Geraud Claret MD?, Mustapha Sebbanne MD, PhD, Xavier Bobbia MD, Jean-Marie Bonnec MD, Stephane Pommet MD, Chawki Jebali MD,

Jean-Emmanuel de La Coussaye MD, PhD

CHU de NimesPole Anesthesie Reanimation Douleur Urgences, 30900 Nimes, France

Received 29 April 2011; revised 7 June 2011; accepted 10 June 2011

Abstract Hospitals implement electronic medical record systems (EMRSs) that are intended to support medical and nursing staff in their daily work. Evolution toward more computerization seems inescapable. Nevertheless, this evolution introduced new problems of organization.

This before-and-after observational study evaluated the door-to-first-medical-contact (FMC) times before and after the introduction of EMRS. A satisfaction questionnaire, administered after the “after” period, measured clinicians’ satisfaction concerning computerization in routine clinical use. The following 5 questions were asked: Do you spare time in your note taking with EMRS? Do you spare time in the medical care that you provide to the patients with EMRS? Does EMRS improve the quality of medical care for your patients? Are you satisfied with the EMRS implementation? Would you prefer a return to handwritten records?

Results showed an increase in door-to-FMC time induced by EMRS and a lower triage capacity. In the satisfaction questionnaire, clinicians reported minimal satisfaction but refused to return to handwritten records.

The increase in door-to-FMC time may be explained by the improved quantity/quality of data and by the many interruptions due to the software. Medical reorganization was requested after the installation of the EMRS.

(C) 2012


Emergency departments (EDs) have played a key role in Health information technology developments [1,2]. Dinh and Chu [3] showed that there is a reluctance to use EMRS among clinicians, recognized barriers to implementation, and showed that there are significant potential benefits to doing so. Electronic medical record system was found to improve the quantity of data captured over handwritten records [4]. In

* Corresponding author.

E-mail address: [email protected] (P.-G. Claret).

fact, computerization can be an effective way to improve safety [5], quality of care [6], and performance [7].

Implementation of EMRS might also have unanticipated consequences [8]. Piasecki et al [9] reported that EMRS implementation is cost saving for nonphysician staff time but actually found the opposite regarding physician time. However, although implementation of EMRS increased the physician time spent on the computer, direct patient contact time was not decreased [5]. The use of template-assisted documentation in the ED was associated with Physician satisfaction and did not decrease the physician evaluation time [10], and clinicians perceived the EMRS to have minimal impact upon patient care.

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.06.014

The purpose of this study was to evaluate the door-to- FMC times before and after the introduction of EMRS in our ED.


Study design

This was a before-and-after observational study, with a Satisfaction survey performed after the “after” component of the study. Door-to-FMC time was defined as the time from initial patient registration to the time when the emergency physician began to write the patient’s observational note. The primary metric was the comparison of door-to-FMC time before and after implementation of EMRS. The secondary metric was the characteristics of the answers from the capacity of triage, the learning curve of the new system, and the satisfaction questionnaire.

The study was reviewed and approved by our institutional review board. All data were kept confidential and were stored in a protected computer. The investigators had complete independence in developing the survey, collecting the data, analyzing the data, and reporting the results.


The study was set in the ED of a university hospital with an annual census of 60 000 patients. The ED implemented an EMRS on October 6, 2009, for use 24 hours a day, 7 days a week, to replace the pen-and-paper system. This EMRS has the following functions: administrative recording, triage, and tracking and reporting patient orders and results. The EMRS triage function was linked with the Canadian ED triage and acuity scale (CTAS) that recommends a time-to-physician assessment based on triage Acuity level. A total of 28 emergency physicians worked in the ED.

Selection of participants

Two periods were defined. The first period was from May 7, 2009, to May 21, 2009 (before EMRS implementation), and the second was from October 16, 2009, to January 15, 2010 (after EMRS implementation). All patients admitted to the ED during these periods were included. Door-to-FMC times greater than 600 minutes were excluded and were considered to be administrative errors. Level 1 ratings from the CTAS were excluded because emergency care has priority over observational note taking. One period of 2 weeks was compared before EMRS installation (from May 7, 2009, to May 21, 2009), and 6 periods of 2 weeks after this installation to test the learning curve. During these 7 periods, the number of emergency physicians, residents, and medical students remained identical. At the end of the EMRS implementation, all physicians who worked in the ED were asked to complete a questionnaire.

Methods of measurement

During the “before” period, the existing administrative software computerized time of admission was used. A medical student, specifically employed for this study, recorded the time when each physician started to write his observational note. During the “after” period, time of admission was noted by the same method as during the “before” period, and the time when the physician started to write his observational note was automatically recorded using the EMRS (Clinicom; Siemens Health Services, Munich, Germany).

At the end of “after” period, a satisfaction questionnaire with 5 questions was distributed to all of the emergency physicians. The questions were as follows:

  1. Do you spare time in your note taking with EMRS?
  2. Do you spare time in the medical care that you provide to the patients with EMRS?
  3. Does EMRS improve the quality of medical care for your patients?
  4. Are you satisfied with the EMRS implementation?
  5. Would you prefer a return to handwritten records?

Answers were evaluated using Visual Analog Scale graduated from -50 to 50, where -50 represented yes; 0, a neutral opinion; and 50, no. Thus, answers ranged between

-50 and 50.

Primary data analysis

The door-to-FMC times and responses to the question- naire items were summarized using means (+-SD) and medians (first and third quartiles). The Student t test was performed to compare door-to-FMC time. The triage capacity was explored using bivariate relationships between levels 2, 3, and 4 during the same periods. The learning curve of the EMRS was also explored using bivariate relationships between consecutive periods. Data were analyzed and represented with R project (free software foundation’s, GNU general public license), Numbers (Apple, Cupertino, CA), and Excel (Microsoft, Santa Rosa, CA). Two-sided P values of less than .05 were considered to be of statistical significance.


The “before” period included 1382 admissions from May 7, 2009, to May 21, 2009. In this period, 62 patients at level 1 of CTAS were excluded. The “after” period included 14 043 from October 16, 2009, to January 15, 2010. From the second period, 1265 admissions were excluded because door-to-FMC times were greater than 600 minutes or aberrant and 681 patients were at level 1 of CTAS.

Door-to-FMC before and after EMRS implementation

Before EMRS was implemented, the mean time between registration and the writing of the patient’s observational note by the emergency physician was 60 +- 54 minutes. After EMRS was installed, this time increased to 118 +- 77 minutes (P b .01). Before EMRS implementation (Q0), mean door-to-FMC time was 61 minutes for level 2, 52 minutes for level 3, and 62 minutes for level 4 acuity patients. After EMRS implementation, this time increased for all levels. For the last period from January 1, to 15, 2010 (Q7), it was 90 minutes for level 2, 124 minutes for level 3, and 119 minutes for level 4. Mean delays between CTAS levels 2 (1 hour 1 minute +- 1 hour), 3 (52 +- 48 minutes), and 4 (1 hour 2 minutes +- 52 minutes) are statistically different during the first period before EMRS. They are not different during 4 periods of 2 weeks after EMRS (Q1, Q2, Q3, Q4). These delays are not significantly different after the EMRS installation (Fig. 1).

Satisfaction questionnaire

Fig. 2 shows emergency physicians’ answers. The response rate was 100%. Only 7 of 28 ED physicians felt that they saved time in their note taking. Only 4 of 28 ED physicians reported that they saved time in the medical care that they provide. Of the 28 ED physicians, 21 felt the EMRS improved the quality of medical care for their patients, and 19 of 28 ED physicians reported that they are satisfied with the EMRS implementation. Only 3 of the 28 ED physicians preferred a return to handwritten records.


Increase in door-to-FMC time

There was an increase in door-to-FMC time after the EMRS was installed. Clearly, the EMRS implementation resulted in an important use of computers. Yen et al [11] showed the addition of computerized physicians’ Order entry to a pediatric ED increased time spent on the computer, but this additional time on the computer is allocated from non- Patient Care Activities.

Moreover, we can speculate that there are 2 major causes for this increase. Firstly, EMRS improves the quantity of the data captured over handwritten records [4]. The implemen- tation of the new EMRS led physicians to better write their observations. Previous studies proposed solutions, such as the use of physician scribes, in concert with the EMRS. Researchers have seen a 6.45% increase in productivity based on patients seen per hour with the addition of computerized records, and with the additional use of a scribe, physicians could focus on the bedside and look at the patient at the same time the scribe enters information into the EMRS [12]. In another retrospective study, ED physician use of a scribe was associated with improved overall productiv- ity, as measured by patients treated per hour but not as measured by turnaround time to discharge [13].

Secondly, interruptions occur commonly during clinical activities in the ED [14]. Moreover, the EMRS requires more validation processes and is itself a cause of interruption. It is likely that these interruptions increased the door-to-FMC time; interruptions have been implicated as a cause of clinical inefficiency [15]. Disruptive behaviors in the ED have a significant impact on team dynamics, communication

Fig. 1 Evolution of the mean delay between door to FMC before and after the implementation of an EMRS and learning curve.

Fig. 2 Physicians’ answers from the satisfaction questionnaire.

efficiency, information flow, and task accountability, all of which can adversely impact patient care [16].

The increase in Patient evaluation time was underlined as a problem by the emergency physicians and nurses in our ED. Corrective actions were made, including a medical reorganization that added 1 emergency physician per day.

Feufel et al [17] revealed the role of EMRS in facilitating or hindering the coordination of time-sensitive and context- dependent distributed work as well as the specific influence of electronic medical record. Authors suggest several requirements for the design of EMRS to promote workplace efficiency [17].

Lower triage capacity

For patients with strokes, computerized triage reduced the interval from ED arrival to evaluation [18]. It was demonstrated that computerized triage was as accurate as or more accurate than the Manual method [19]. These positive results were not observed in our study. Immediately after the installation, we observed a worsening in triage capacity.

Minimal satisfaction but refusal to return to handwritten records

Physicians who use EMRS believe that the system improves the quality of care. Nevertheless, the increased Delay in care is the principal shortcoming reported by the emergency physicians. Paradoxically, physicians seem satisfied with the implementation because of the improve- ment in the quality of care. There are different hypotheses to explain these results. Firstly, prescribing errors are the most frequent source of adverse drug events, and computerized physician order entry systems are widely viewed as crucial for reducing prescribing errors [20]. Secondly, Chisolm et al [21] suggested that satisfaction with an ambulatory EMRS is strongly associated with perceptions of the system’s usefulness and with the level of technical support. Lastly, it was shown that EMRS improved the quality of communica- tions, as all of the pertinent information is available without having any problems with handwriting legibility [22]. Few would like to return to pen and paper. These results are in agreement with others that found that EMRS are likely to outscore conventional paper recording systems [23].


Firstly, this study was performed at a single institution, and our results may not be representative of other institutions. Secondly, illness due to 2009 H1N1 Influenza infections was clustered in October and November. Subsequently, the first weeks of the study took place during a pandemic period. Thirdly, although other studies have shown that EMRS or computerized physician entry was associated with a significant reduction in ED length of stay overall [24,25], our sense is that EMRS implementation did not decrease the length of stay. Nevertheless, length of stay was not measured

in this study.

Lastly, the method for recording the time when the emergency physician began to write his observational note changed.


Emergency department implements EMRSs that are intended to support medical and nursing staff in their daily work, but this evolution entails new problems of

organization. In this before-and-after observational study, the time from initial registration to the time when the physician started to write the patient’s note increased after EMRS implementation. Nevertheless, although clinicians reported minimal satisfaction, they refused to return to handwritten records. Corrective actions were made, and medical reorganization was requested after the installation of the EMRS.


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