Baylor University Medical Center Proceedings April 2017 - 147

Pre and post hoc analysis of electronic health record
implementation on emergency department metrics
Kyle J. Rupp, DO, MBA, Nathan J. Ham, DO, Dennis E. Blankenship, DO, Mark E. Payton, PhD,
and Kelly A. Murray, PharmD

Longitudinal time-based emergency department (ED) performance measures were quantified 12 months before and 12 months after (March
2012-February 2014) implementation of a Meditech 6.0® electronic
health record (EHR) at a single urban academic ED. Data assessed were
length of stay from door to door, door to admission, door to bed, bed to
provider, provider to disposition, and disposition to admission, as well
as number of patients leaving against medical advice and number of
patients leaving without being seen. Analysis of variance was used to
compare levels before and after EHR implementation for each variable,
with adjustments made for the number of admissions, transfers, and
month. No difference was seen in monthly volume, admissions, or transfers. Implementation of an EHR resulted in a sustained increase in ED
time metrics for mean length of stay and times from door to door, door to
admission, door to bed, and provider to disposition. Decreased ED time
metrics were seen in bed-to-provider and disposition-to-admit times.
The number of patients who left against medical advice increased after
implementation, but the number of patients who left without being seen
was not significantly different. Thus, EHR implementation was associated with an increase in time with most performance metrics. Although
general times trended back to near preimplementation baselines, most
ED time metrics remained elevated beyond the study length of 12 months.
Understanding the impact of EHR system implementation on the overall
performance of an ED can help departments prepare for potential adverse
effects of such systems on overall efficiency.

n increasing number of hospitals and health care centers
are adopting electronic health record (EHR) systems
with the goal of improving health care quality while
potentially decreasing costs (1). However, there are concerns regarding how eﬃciency and physician productivity are
aﬀected secondary to EHR implementation. Unlike ambulatory
and inpatient settings, where patient volume can be adjusted
to help with this transition, EDs are unable to alter volume
and must maximize eﬃciency during this process. Currently,
limited data exist in the ED literature showing the eﬀects on
productivity and the length of those eﬀects, and research has
shown that errors and unanticipated problems will arise from
implementation (2). In addition, while computer physician
order entry (CPOE) can provide many beneﬁts when orders
need to be placed and processed quickly (3), its implementation
Proc (Bayl Univ Med Cent) 2017;30(2):147-150

has unanticipated adverse eﬀects, such as workﬂow issues, difﬁculties in the transition away from paper records, increased
system demands, overdependence on technology, and loss of
professional autonomy (4), which may aﬀect overall department eﬃciency, resulting in ED crowding (5-7) and patient
elopement (8). Several crowding measures have been endorsed
by the National Quality Forum and Joint Commission, such
as ED length of stay (LOS), waiting times, disposition to admission times, and rates of patients leaving without being seen
(9, 10), and soon hospitals will report ED crowding measures
to the Centers for Medicare and Medicaid Services to receive
full Medicare payment (11). To date, little to no data exist
showing results for an extended period of time surrounding
the implementation of an EHR system. The objectives of this
study were 1) to describe the eﬀects of EHR implementation
on various ED-speciﬁc metrics over the course of 12 months
and 2) to compare those metrics to the 12 months prior to
EHR implementation.
METHODS
This retrospective analysis of ED metrics was performed at
a single urban, university-aﬃliated, public, 25-bed ED in Tulsa,
Oklahoma, with an emergency medicine residency program and
an annual ED census of roughly 46,000. The ED was staﬀed
with board-certiﬁed emergency physicians, emergency medicine
residents, and other rotating residents from various services (i.e.,
internal medicine, family medicine, surgery, etc.).
Prior to implementation, the ED utilized paper documentation sheets, dictation, and written physician order entry via
a clerical tech. Meditech 6.0® was implemented in the ED in
a stepwise manner on March 1, 2013, with implementation
completed on May 7, 2013. The ﬁrst step involved implementation for registration, medical records review, laboratory, radiograph results, and electronic ED tracker board. Physician
From CHI Health-Good Samaritan Hospital, Kearney, Nebraska (Rupp); Questcare
Partners, Dallas, Texas (Ham); Oklahoma State University Center for Health
Sciences, Tulsa, Oklahoma (Blankenship, Murray); and Oklahoma State University,
Stillwater, Oklahoma (Payton).
Corresponding author: Kyle J. Rupp, DO, MBA, Medical Director, Emergency
Services, CHI Health-Good Samaritan Hospital, 10 East 31st Street, Kearney,
NE 68847 (e-mail: KyleRupp@catholichealth.net).
147

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings April 2017