Rapid Electronic Provider Documentation Design and Implementation in an Academic Pediatric Emergency Department

Many emergency departments are transitioning from paper charting to full electronic health records, which include both computerized provider order entry and provider documentation. Implementation of electronic provider documentation (EPD), in particular, has been challenging. Known benefits include legibility, medicolegal and compliance safeguards, and improved access to patient charts. Offsetting these benefits may be reductions in efficiency, patient throughput, and less provider-patient interaction.

We used a rapid design process coupled with Lean principles, simulation, aggressive training, and continuous process improvement to design and implement a novel EPD system with real-time voice recognition dictation in the pediatric emergency department (PED). We used statistical process control methodologies to compare mean PED lengths of stay (LOSs) for admitted and discharged patients before and after EPD GoLive.

We were able to design, test, train, and implement a novel EPD to the PED within 7 months. There was special cause variation, with a 2.7% (5-minute) increase in overall LOS after EPD implementation. There was a temporary 9.3% (15-minute) increase in discharge LOS for 6 weeks after GoLive, with a subsequent return to a new baseline of 4.3% (7-minute) increase. There were no significant changes in admission LOS. There was overall consistent use of the voice recognition system several months after EPD rollout. There have been improving rates of compliance with chart completion over time, as a result of easier tracking and electronic reminders to complete.

Despite the inherent challenges involved in transitioning from paper charting to EPD, our study showed that an academic ED, EPD, can be rapidly designed and implemented while not significantly negatively impacting ED metrics such as LOS. We had consistent use of the voice dictation system after implementation. Time spent documenting after clinical shift was not reliably captured and is an important area of future research for successful EPD implementation.