Get wired’Up-to-date clinical information and valuable resources are available on the Internet
ED managers should combat the perception of the Internet as a forum for chats and games and encourage clinical staff to reap the benefits of instant access to information
Although the Internet, the "information superhighway," and the World Wide Web have been household words for years, the instant access to information the Internet provides is only just beginning to trickle down into the ED. This is a valuable resource for both managers and clinical staff, according to William H. Cordell, MD, FACEP, director of emergency medicine research and informatics at Methodist Hospital in Indianapolis, which has Internet access on every PC in the ED. "The Internet has the potential to transform how we deliver health care and practice emergency medicine," he emphasizes.
The Internet will play an increasingly key role in the ED, predicts Joseph E. Clinton, MD, FACEP, chief of emergency medicine at Hennepin County Medical Center in Minneapolis and professor of clinical emergency medicine at the University of Minnesota. "It’s a ready source of information that will improve the quality of care and the efficiency of communication."
ED nurses and physicians should consider the Internet an essential resource. "Clinicians really have an obligation to spend some time looking at clinical sites and join some listservs and discussion groups," emphasizes Brian Duggan, MSN, RN, CEN, CNS, clinical systems project manager for Carolinas HealthCare System in Charlotte, NC, and chair of the information systems committee and webmaster for the Emergency Nurses Association. "After a month of concerted effort, you will see some clear benefits to your practice."
ED managers should be prepared for resistance from administrators who envision staff "surfing the Web" inappropriately. "That’s administration’s biggest fear, that staff will waste a lot of time," says Duggan. "It’s certainly a possibility, since people can look real busy sitting in front of a computer when they’re just playing around."
But staff who are looking to waste time can do so with or without the Internet, he points out. "You can gossip or read a novel instead of playing on the Internet," Duggan says. "Refusing [to give the] staff Internet access because you’re afraid they’ll waste time isn’t a good solution, because you’re taking away a potentially valuable resource."
Reluctant administrators should be given a hands-on demonstration of how the Internet will benefit ED staff. "You should take them onto the Internet and show them exactly how the staff will use it," Duggan recommends. "Also, you need to explain how you intend to prevent staff from abusing it."
"Forbidden" web sites can be filtered out with software locks, but those won’t solve the problem, says Duggan. "You can filter out everything with the word sex’ in it, but that doesn’t help you as a clinician," he explains.
A straightforward approach is better, he says. "You need to explain what is appropriate use of the Internet and keep an eye on the staff," Duggan recommends. "That doesn’t prevent them from going to other sites, but to some degree you have to trust your staff."
The concern of wasting time is overstated, Cordell argues. "Preventing unauthorized use’ of the Internet has not been a big problem for us," he says. "In the ED, the computers are all out in the open and clandestine surfing of forbidden fruit is difficult."
Clinicians need to develop an "information-seeking" habit, and shouldn’t be discouraged from exploring the Internet, he argues. "Sure, during lull times, I’ve seen colleagues looking up which stove is the best, or information about classic automobiles, but who cares?" Cordell asks. "Don’t forgetthis is what gets people enthused and "hooked" on the technology."
Here are some uses of the Internet in the ED:
Literature searches. Staff have studies, abstracts, and literature at their fingertips. At Methodist Hospital’s ED, literature searches are routinely done via the Internet. "There is a wealth of emergency medicine-related information on the Internet," says Cordell. "We access Medline through the Internet browser and do real-time searches for teaching residents and students. Other faculty access Emergency Medical Abstracts to run quick searches on topics. Abstracts can be identified, printed out on the network printer, and discussed with the student, resident, or nurse."
Staff should be cautioned that the information found on the Internet isn’t always accurate or current. "The Internet is totally unregulated and it’s certainly buyer beware.’ There is a lot of folklore and unscrupulous Web sites out there, which is a problem that comes up," says Todd Taylor, MD, FACEP, an attending emergency physician at Good Samaritan Regional Medical Center and Phoenix (AZ) Children’s Hospital and former chair of ACEP’s section for computers in emergency medicine.
Teaching tools. The Internet is an excellent educational tool for residents and staff at teaching hospitals. "If we’re talking about treatment of myocardial infarction and a new paper was just published, we can look up the abstracts so residents can read it and access it for their own files," says Clinton
Residents and students should be exposed to the Internet on a routine basis. "People have to be trained from the bottom up, so residents should be encouraged to use the Internet frequently," says Taylor. "It’s a tool that people need to learn to use, so it should be part of the curriculum."
Medline is used during clinical shifts in Methodist Hospital’s ED for teaching and patient care. When Cordell worked with a resident on the case of elderly man with a "red eye" and loss of sight in his right eye, they noticed the eye exhibited an obvious corneal ulceration. "This was a case of a hypopyon, or accumulation of pus in the anterior chamber of the eye," recalls Cordell. "Because this is a rather unusual condition, we were able to conduct a real-time search and read up on it together."
Maximizing space. Storage space for reference manuals and in-house resources may be freed up. "I can see in the future we won’t need as many books around, because people can get those same resources online," says Marcia Zimmerman, RN, MA, clinical systems coordinator at Hennepin County’s ED.
Consulting with colleagues. The ED at St. Francis Hospital in Tulsa, OK, now has Internet access in the academic offices, with plans to add ED access. "I can now contact colleagues over the Internet during working hours instead of waiting until I’m home," says William Bickell, MD, FACEP, associate director of emergency services at St. Francis and medical director of Tulsa Life Flight. "Putting out queries or requests with problems is also useful, since newsgroups allow more rapid spread of knowledge by networking and chatting with people about patient care issues or administrative problems."
The Internet is an efficient way to contact faraway colleagues. "E-mail is my No. 1 means of communicating with colleagues in the United States, Canada, and elsewhere," says Cordell. "I also subscribe to several list servers to post difficult clinical questions and garner responses."
Reaching prospective residents. Hennepin’s department of emergency medicine has its own Web page. "The primary reason we put it together was to provide information to prospective residents," says Clinton. "It contains the type of information medical students frequently call the department for, and this is a more efficient method than sending it by mail."
The web page contains background on faculty members, ongoing research at the university, and videos of interesting patient cases. Internally, ED physicians can use the Web page to check on their monthly schedules.
At Indiana University School of Medicine’s department of emergency medicine, the faculty have their own Web page in addition to a site for the ED residency program. (The address for the residency web site is http://www.iupui.edu/~emergmed/. Once you’ve opened the site, you can click on "Sections" to access the faculty site.)
Improving patient care. The ED environment doesn’t allow for on-the-spot online consultation with colleagues. "Emergency medicine is not the kind of practice that lends itself to long investigatory stuff," says Taylor. "If a patient comes in who ingested a toxic substance, it’s quicker to call the poison control center or talk to a toxicologist than to pull it up on the computer."
Still, many ED physicians find the Internet has a direct impact on patient care. "Many of us are doing real-time Medline searches to answer questions generated while taking care of patients," says Cordell. Answering questions at the "point of care" is an invaluable learning tool, he says. "Unless the information is readily accessible, the questions that get generated during the course of any ED shift won’t be answered. Instead, we often default to habit."
Many ED experts speculate that the best way to learn is to constantly read current information relevant to specific cases, says Cordell. "The desire to learn is perhaps greatest when applied to a specific, real patient. This presents an enormous opportunity to put quality reference information at the point of care to be used not only to better patient care, but as a learning tool." n
Five ways to battle computerphobia’
Although Internet access is arriving in EDs, many ED staff members just aren’t interested in taking advantage of the Internet’s resources. "The biggest problem is computerphobia," says Todd Taylor, MD, FACEP, an attending emergency physician at Good Samaritan Regional Medical Center and Phoenix (AZ) Children’s Hospital and former chair of ACEP’s section for computers in emergency medicine.
ED staff may not view themselves as computer literate. "Many of us aren’t fully utilizing what’s available out there," says Taylor. "The problem is that the Internet isn’t as organized as it could be for the common user. As a result, computer geeks still utilize it more than the next guy."
Often, nurses and physicians resist using the Internet, doubting it can improve their clinical practice. "There is a tendency for people to say, I can do my job without it.’ But, they are closing themselves off to great resources and interaction with colleagues, which is a big mistake," says Brian Duggan, MSN, RN, CEN, CNS, clinical systems project manager for Carolinas HealthCare System in Charlotte, NC, and chair of the informations systems committee and webmaster for the Emergency Nurses Association.
Here are five ways to make the Internet user-friendly for first-time users in the ED:
1. Make it easy to start. Although many staff members may have experience surfing the Web on their home PC, it’s a good idea to help point clinicians to useful sites. "There is an art to doing Internet searches. Search engines rarely give you what you’re looking for the first time; you might get a bunch of garbage and get frustrated," says Duggan, who created a Web page called "Beginner’s Leap" specifically for clinicians new to the Internet. (The address is: http://members.aol.com/bDugganrn/ena.)
2. Open the door with e-mail. Even computerphobes enjoy communicating with colleagues via e-mail. "E-mail is something that people can really latch onto quickly," says Taylor. "It’s a good place to start, because there is an immediate reward, and you can then branch out from there."
3. Subscribe to listservs. Listservs, Internet e-mailing lists that deal with a particular topic, are an excellent way to network with colleagues. "They are great educational resources if you need to develop a policy or have staffing questions," says Duggan. "They are very helpful for ED managers and staff members working on projects, so you’re not reinventing the wheel."
When someone subscribes to a listserv, they receive messages posted by other members on the listserv’s topic and can submit their own replies and messages to the group.
Choose list servers carefully to avoid receiving an overwhelming glut of messages. "Limit your subscriptions, because you can get hundreds of e-mails every day before long," says Duggan. Another solution is to request the condensed version, which is a single message containing all of the day’s e-mails. "That makes it a lot more manageable," says Duggan. "If you send a "help" command to listserv [the program or person moderating the list], it will send you back a bunch of options including getting the digest’ version of the e-mails, which makes life much easier."
4. Offer something of value to a clinician. People will not learn new technology unless they have a reason to do so, says Taylor. "In the ED, there are too many other pressing needs. The only way to get a group of people to do it is to create the need," he states. Clinicians should be shown useful online offerings such as patient education materials that can be printed out and distributedbut only if they are from reputable sources. "HealthMed publishes 500 or so, from organizations such as the American Heart Association or American Lung Association," says Duggan.
5. Create a home page in the ED. Having a home page that automatically appears on the screen will point people in the right direction. "Anybody who is thinking about putting the Internet in their ED ought to also build a Web site of their own, so it automatically opens up to that home page directing the user to clinically relevant data," says Duggan.
The Web site should encourage staff to participate in sharing their own sites via a submission form, Duggan recommends. "You should make it as interactive as possible with the staff, so they are encouraged to use this great informational resource," he says. n
Here is a partial listing of web sites and listservs:
List servers:
• Critical Care Medicine Address: [email protected] Message to Subscribe: subscribe ccm-1 (insert your email address)
• Emergency Medicine List Address: l[email protected] Message to Subscribe: subscribe emed-1 (insert your name)
• Pediatric Emergency Medicine Discussion List Address: l[email protected] Message to Subscribe: subscribe ped-em-1 (insert your name)
• Wilderness Emergency Medicine Address: [email protected] Message to Subscribe: subscribe wilderness-emergency-medicine (insert your name/email address)
• Morbidity and Mortality Weekly Report Address: [email protected] Message to Subscribe: subscribe mmwr-asc (insert email address)
• MedNews Address: [email protected] Message to subscribe: subscribe mednews
• Disaster Medical Assistance Teams (DMAT) Address: [email protected] Message to subscribe: subscribe dmatnews address@ (insert email address)
• Hazardous Materials Emergency Response Address: [email protected] Message to subscribe: subscribe hazmatmed (insert e-mail address)
• Disaster Emergency Response Association Address: [email protected] Message to subscribe: subscribe dera (insert e-mail address)
Web sites:
• The Library of Congress recently offered free access to Medline. Address for Library of Congress home page with access to Medline: http://www.nlm.nih.gov
• American College of Emergency Physicians http://www.acep.org
• Emergency Nurses Association http://www.ena.org
• Society for Academic Emergency Medicine http://www.saem.org
• MedscripWindows Prescription Writer for Physicians http://www.rust.net/~skindell/medscrip.html A fully automated, computerized and portable Windows prescription writer.
• Emergency Medical Systems http://www.njnet.com/embbs/soft/ems/home.html Electronic charting and patient/information management systems primarily for the ED setting.
• Medical Manager by Systems Plus http://www.wp.com/bytebloc/home.html Provides financial, clinical, and practice management modules.
• Medical Software Catalog http://www.medsoft.com Products include CD-ROM products such as the Medline CD-ROM, multiple journals, and the Mosby Electronic Library, scheduling software, telephone triage software, and prescription writers.
• VoiceEM http://www.pbol.com/voice_recognition/vmeddes.html
Kurzweil Applied Intelligence’s speech recognition system for emergency medicine physicians.
• IBM VoiceTYPE Dictation http://www.magic.ca/~voicesys/ibmvtype.html Speech recognition system with optional vocabulary of 16,000 ED medical terms.
• Professional Medical Software http://chelsea.ios.com/~profs19/emed.html Emergency medicine CD-ROMs containing full text from over twenty primary care books.
• General Medical File Library http://home.unicomp.net/microbbs/medical.html Listing of shareware programs and demonstration programs supplied by vendors, with several programs applicable to emergency medicine.
• Iliad, a Medical Diagnostic Support Program http://www.ami-med.com/ildprodc.html An expert system that can suggest relevant diagnoses and give advice regarding cost-effective workup strategies.
The intranet: It’s coming to your ED
Just as soon as staff members grow accustomed to the Internet, they’ll have to learn a new termintranet. An intranet is basically an internal Internet that allows EDs to access internal patient medical information online. "Internal documents, previously in paper form in binders, could be posted on the Intranet and accessed only from within the institution and not from the outside," says William H. Cordell, MD, FACEP, director of emergency medicine research and informatics at Methodist Hospital in Indianapolis.
In the near future, Methodist Hospital and Clarian Health Partners will be posting all ED documents and memos in archival form on their intranet, which will greatly benefit emergency physicians, says Cordell. "If a policeman asks the emergency physician to draw a blood alcohol on a trauma victim, typically you’d have to find the binder that contains the policy du jour," he explains. "As we all know, paper documents stored in a single place are notoriously difficult, frustrating, and labor-intensive to access. The intranet would allow physicians and nurses to go into a "folder" and read the most current policy."
A pilot study of an intranet underway at two sites within the Carolinas Health Network in Charlotte, NC, will measure the benefits to ED physicians, says Brian Duggan, MSN, RN, CEN, CNS, clinical systems project manager.
The intranet is expected to benefit emergency physicians in several ways. "They may not be sure which endocrinologist a patient’s insurance plan covers," says Duggan. "Right now, they have to make time-consuming calls, but the intranet will have the list of every insurance company’s list of approved referrals so they can do a search right there in the room."
Likewise, the type of medication covered by insurance plans will be on the intranet. "Often, patients get to the pharmacy and find out their insurance doesn’t cover their prescription as written," says Duggan. "Then, the physician has to get on the phone and approve a change. These things sound small, but they give the physician a lot of added value to their day."
Advent of the electronic medical record
Development of intranets is also expected to facilitate the switch to online electronic medical record-keeping. "In the future, we’ll probably be able to exchange data on patients with other facilities," says William Bickell, MD, FACEP, an emergency physician at St. Francis Hospital in Tulsa, OK. "It’s a pretty cumbersome process right now. If someone’s been in another hospital, we fax over a waiver and hope they send us something readable back. It would nice to be able to cruise thought an electronic medical record, but for most hospitals, that doesn’t exist."
When an electronic medical record is a reality, the ED physician’s practice will change dramatically, with instant access to patient drug profiles and medical records from around the world. "The real power of the Internet will be the virtual electronic medical record," predicts Cordell. "Bits of a person’s record, such as an ECG, might be in a database in Indianapolis, and another bit, a digitized chest x-ray, might be stored in a data repository in Moscow. They could be virtually linked using the Internet." To the user accessing them, it would appear the data are in one place. Video, such as echocardiograms, and sound, such as heart sounds, may also be accessed through an online record.
A project is currently under way using a computerized medical record. The Indianapolis Network for Patient Care and Research links data from three EDs, 50 community pharmacies, 10 clinics, four HMOs, and 12 homeless care sites in Indianapolis. The project will compare the frequency of test ordering, ED visit charges, length of ED visits, and the number of hospital admissions per ED visit, and ED return visits within 30 days.
The Internet will offer ED managers other exciting possibilities in the next few years, such as attending an ACEP conference without leaving your home. "Instead of 4000 emergency physicians travelling 2000 miles to San Francisco and paying $200 for a hotel room, you’ll be able to sit there and watch it on your computer from home, respond back, and ask questions," predicts Todd Taylor, MD, FACEP, an attending emergency physician at Good Samaritan Regional Medical Center and Phoenix Children’s Hospital.
[Editor’s Note: For more information on the Indianapolis Network for Patient Care and Research, contact the Regenstrief Institute for Health Care, Indiana University School of Medicine, 1001 W. 10th Street, 5th Floor, Indianapolis, IN 46202. Telephone: (317) 630-7626. Fax: (317) 630-6962.]
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