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

Abstract

Background 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. 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. Methods Until 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. Results All 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). Conclusions We 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.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system

“…7,8 Multiple studies have reported the advantages of EDIS, such as improvement of usability, 9 study recruitment, 10 visual representations, 11 and data collection. 12 Several studies have utilized artificial intelligent algorithms to automatically extract structured information from clinical notes in EMRs. 13,14 In Japan, the Next Stage ER system (NSER; TXP Medical Co. Ltd, Tokyo, Japan) has been increasingly implemented in EDs of university and tertiary care hospitals.…”

“…Over the last decade, the emergence of integrated emergency department information systems (EDISs) has changed emergency department (ED) administration and data management 7,8 . Multiple studies have reported the advantages of EDIS, such as improvement of usability, 9 study recruitment, 10 visual representations, 11 and data collection 12 . Several studies have utilized artificial intelligent algorithms to automatically extract structured information from clinical notes in EMRs 13,14 .…”

Adopting an American framework to optimize nursing admission documentation in an Australian health organization

“…From a historical point of view, studies have described processes of transitioning from paper to electronic documentation in nursing and healthcare in general. [13,17,18] Implementing electronic documentation in nursing has standardized various formats of paper-based admission forms in Australia, some of which were directly automated into an electronic format. [15] From a socio-technical point of view, form content and design are often informed by working groups with physicians, nurses, clinical managers or administrators, health informaticians, and technical staff as key players.…”

South African and international legislature with relevance to the application of electronic documentation in medicolegal autopsies for practice and research purposes

“…There is an urgent need to rapidly upgrade the current paper record keeping system, which results in missing or empty files, into an electronic system. It should be obligatory to stay abreast with technological development when other medical disciplines have far advanced into this territory, even in resource limited countries (Wilson and Khansa 2018;Grange et al 2020;Katurura and Cilliers 2018;Lucas et al 2019;De Pietro and Francetic 2018;Zayyad and Toycan 2018). Nevertheless, there is a multitude of reasons why this forms a conundrum in forensic medicine just as it does in medicine (Ambinder 2005;Kalougivaki 2014).…”