title: Efficiency achievements from a user-developed real-time modifiable clinical information system.
abstract: OBJECTIVE
  This investigation was initiated after the introduction of a new information system into the Nepean Hospital Emergency Department. A retrospective study determined that the problems introduced by the new system led to reduced efficiency of the clinical staff, demonstrated by deterioration in the emergency department's (ED's) performance. This article is an investigation of methods to improve the design and implementation of clinical information systems for an ED by using a process of clinical team-led design and a technology built on a radically new philosophy denoted as emergent clinical information systems.
  
  
  METHODS
  The specific objectives were to construct a system, the Nepean Emergency Department Information Management System (NEDIMS), using a combination of new design methods; determine whether it provided any reduction in time and click burden on the user in comparison to an enterprise proprietary system, Cerner FirstNet; and design and evaluate a model of the effect that any reduction had on patient throughput in the department.
  
  
  RESULTS
  The methodology for conducting a direct comparison between the 2 systems used the 6 activity centers in the ED of clerking, triage, nursing assessments, fast track, acute care, and nurse unit manager. A quantitative study involved the 2 systems being measured for their efficiency on 17 tasks taken from the activity centers. A total of 332 task instances were measured for duration and number of mouse clicks in live usage on Cerner FirstNet and in reproduction of the same Cerner FirstNet work on NEDIMS as an off-line system. The results showed that NEDIMS is at least 41% more efficient than Cerner FirstNet (95% confidence interval 21.6% to 59.8%). In some cases, the NEDIMS tasks were remodeled to demonstrate the value of feedback to create improvements and the speed and economy of design revision in the emergent clinical information systems approach. The cost of the effort in remodeling the designs showed that the time spent on remodeling is recovered within a few days in time savings to clinicians. An analysis of the differences between Cerner FirstNet and NEDIMS for sequences of patient journeys showed an average difference of 127 seconds and 15.2 clicks. A simulation model of workflows for typical patient journeys for a normal daily attendance of 165 patients showed that NEDIMS saved 23.9 hours of staff time per day compared with Cerner FirstNet.
  
  
  CONCLUSIONS
  The results of this investigation show that information systems that are designed by a clinical team using a technology that enables real-time adaptation provides much greater efficiency for the ED. Staff consider that a point-and-click user interface constantly interrupts their train of thought in a way that does not happen when writing on paper. This is partially overcome by the reduction of cognitive load that arises from minimizing the number of clicks to complete a task in the context of global versus local workflow optimization.
authors.affiliation: Department of Emergency Medicine, Nepean Hospital, Penrith, NSW, Australia.
authors.forename: Roderick O
authors.initials: RO
authors.lastname: Bishop
authors.affiliation: Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia. Electronic address: jonpat@icims.com.au.
authors.forename: Jon
authors.initials: J
authors.lastname: Patrick
authors.affiliation: Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia.
authors.forename: Ali
authors.initials: A
authors.lastname: Besiso
mesh_terms: D003199:Computer Systems; D017598:Efficiency, Organizational; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D019451:Information Management; D008331:Management Information Systems; D008490:Medical Informatics / Q000379:methods; D019982:Organizational Case Studies; D012189:Retrospective Studies; D012984:Software; D057188:Workflow