An assessment of the hospital information system in an emergency room: Focusing on a new element of patient safety

INTRODUCTION

The emergency room is a highly dynamic and demanding healthcare environment. It faces numerous operational challenges, including unpredictable patient admissions, varying severity of patient conditions, a high volume of referrals, and significant time constraints for healthcare providers.^[1] These challenges are associated with adverse outcomes such as prolonged wait times, patient dissatisfaction, increased mortality rates, higher medical costs, a rise in medical errors, and an escalation in incidents of violence.^[1] To address these issues effectively, the work in emergencies must be characterized by adaptability and efficient resource allocation.^[2] The continuous collection, aggregation, and timely processing of patient data are critical to improving the quality of emergency care.^[1] Prompt and accurate evaluation of patients is essential to enable timely medical intervention and informed clinical decision-making.^[3,4]

Given the time-sensitive nature of the task in emergencies and the high volume of at-risk patients, robust technological infrastructure, particularly in the form of a comprehensive hospital information system (HIS), is indispensable. A growing body of evidence supports the integration of computer-based systems in healthcare, highlighting their role in improving organizational performance.^[5] One of the most vital components of a HIS in the emergency is the emergency department information system (EDIS), designed specifically to manage patient care workflows and data during emergencies.^[5,6]

The EDIS offers several distinct advantages. These include improved accuracy and efficiency in clinical and administrative data handling, accelerated access to patient information, the elimination of limitations inherent in paper-based records, such as the inability to allow concurrent multi-user access, and enhanced departmental performance through clinical decision support functionalities.^[7] Collectively, these features have the potential to substantially elevate the standard of care delivered in emergency. Despite the growing recognition of EDIS benefits, their adoption remains limited in many healthcare systems, especially in developing countries.^[8-10]

Several barriers hinder widespread implementation, including insufficient funding, inadequate staffing, and the burden of serving large populations. In addition, digital integration of diagnostics and emergency services has demonstrated the capacity to improve patient outcomes by facilitating faster decision-making, reducing manual documentation errors, and decreasing turnaround times (TATs) for diagnostic investigations.^[4,6]

Given the critical nature of the work in emergencies, usability challenges within EDIS must be addressed to minimize the risk of user errors and ensure patient safety. The current study evaluates the knowledge, usability, and perceived effectiveness of the electronic HIS implemented in the emergency, which accommodates 90 admission beds and 100 observation beds, and receives approximately 140,000 patient visits annually. We hypothesize that the current electronic HIS provides an optimal experience among the emergency physicians and supports effective emergency care delivery.

MATERIALS AND METHODS

Data collection

Data were collected through a self-administered, pre-tested, and structured questionnaire to gather users’ feedback (doctors in emergency) on all three software systems. It was used to assess functional, technical, and supportive features. The functional features assessed patient care delivery and clinical decision-making. Technical features assessed the use of standard terminologies and interoperability (bidirectional information exchange between the laboratory and clinical wards). Supportive functions included support for medical research, general health, and healthcare quality improvement. The platform “Google Forms” (via docs.google.com/forms) was used to collect the data. The questionnaire consisted of 50 questions: 12 for PDS, 11 each for LIS and RIS, and 16 for HIS (used for usability scoring), with closed-ended responses – agree, disagree, and neutral. Responses for PDS, LIS, and RIS were rated on a 3-point scale: 2 for “agree,” 1 for “disagree,” and 0 for “neutral.”

To obtain the usability score of the HIS, we prepared 16 separate self-constructed questions in addition to the original system usability scale (SUS) questions. However, we used SUS principles to ensure that the questions were accurate and reliable. We employed a 3-point Likert scale, assigning values of one, two, and three to “Disagree,” “Neutral,” and “Agree,” respectively. The final score was calculated as follows: X = the sum of the scores for all oddnumbered questions minus 3, and Y = 3 minus the sum of the scores for all even-numbered questions. The modified SUS score based on the 3-point Likert scale was then calculated as (X + Y) × 3.125.

As in the original SUS scoring, a system scoring above 70 was considered acceptable; scores from the high 70s to high 80s indicated better systems, while scores above 90 reflected excellent usability. An overall SUS score ranging from 70 to 90 reflects that the system has good-to-excellent usability.[11] No data were missing, as only fully completed questionnaires – with all questions answered – were included in the analysis. The questionnaire was pre-tested in a pilot study before distribution. The results of the pilot study were used to refine the wording, reframe the statements, and restructure the questionnaire flow. Data collected during the pilot study were excluded from the final analysis. The study design is shown in Figure 1.

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Figure 1:

Study design

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RESULTS

This questionnaire-based study was conducted in the emergency room of a referral hospital in Northern India to assess the functionality of the existing electronic HIS. The HIS used in the emergency room was PDS, LIS, and RIS. The study included 103 participant doctors. The study gathered many critical findings.

The mean scores of each participant’s responses for three modules of HIS

Mean scores were highest for LIS (12.8 ± 4.1), followed by RIS (8.5 ± 5.2) and PDS (7.1 ± 6.9) [Table 3]. Figure 2a-c shows error bars for PDS, LIS, and RIS. Group VI showed the best scores for PDS (39%) and LIS (64%), while group IV had the highest overall usability across modules [Figure 3], especially for LIS (14.35). Among all HIS modules, LIS had the highest usability.

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Figure 2:

Shows the error bars for (a) patient display system, (b) laboratory information system, (c) and radiology information system, respectively.

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Table 3: The mean scores of each participant responses for three modules of HIS viz PDS, LIS and RIS.

Module	Total, n=103	Maximum score	Group I, n=24	Group II-IV#, n=52	Group V, n=20	Group VI, n=7
PDS*, Mean±SD	7.1±6.9	24	5.9±7.6	7.5±6.7	6.7±6.4	9.3±6.8
LIS, Mean±SD	12.8±4.1	22	13.2±5.4	12.6±3.5	12.5±4.5	14.1±1.9
RIS, Mean±SD	8.5±5.2	22	8.9±6.0	8.4±4.4	8.8±6.0	6.9±5.4

The mean PDS, LIS and RIS scores were compared across respondents using a one-way analysis of variance test. *The P-value was statistically significant for PDS (P=0.027). #Post hoctest comparison using the Tukey honestly significant difference test showed a statistically significant P=0.036 between Group II and Group IV for the PDS module SD: Standard deviation, PDS: Patient display system, LIS: Laboratory information system, RIS: Radiology information system, HIS: Hospital information system

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Figure 3:

The compound bar represents the mean responses of all participants in three different HIS modules: PDS, LIS, and RIS. PDS: Patient display system, LIS: Laboratory information system, RIS: Radiology information system, HIS: Hospital information system.

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DISCUSSION

A sound and comprehensive information system in the emergency room can reduce documentation errors, improve patient treatment, and boost patient and clinician satisfaction.^[1] Such systems can support healthcare providers by assisting in clinical decision-making and offering patients relevant information about their symptoms, medical conditions, and potential next steps.^[12,13] In high-pressure environments such as triage and emergency departments, where time constraints and patient volumes are significant, the risk of human error increases. The fast-paced nature of these settings, coupled with the severity of many cases, contributes to this vulnerability. Research suggests that physicians may have a diagnostic error rate of approximately 5%, with nearly half of these errors having the potential to cause patient harm.^[14]

This questionnaire-based study was conducted in the emergency room of a referral hospital in North India to assess the functionality of the existing electronic HISs. It gathered many critical findings. The foremost finding was that most users were young doctors with user experience of <5 years. 30% of them were unaware of the PDS in the emergency. This may reflect the requirement for re-induction training for newly joined residents in the emergency room on the available software for patient care. An induction program (IP) designed meticulously for the resident doctors may improve performance. Patel and Patel have shown that IPs are necessary to prepare doctors for practice and improve patient outcomes.^[15] In contrast, this study revealed that a higher awareness was observed for the LIS and RIS. This could be explained by the higher motivation centered around the need for accurate and quality diagnostics and the basic and mandatory requirements for clinical decision-making.^[16]

The second important finding was that overall, the existing HIS eased the daily working procedures for the physicians and made information acquisition easy, which aided in providing correct and timely management. This study found that the HIS demonstrated good to excellent usability, effectively supporting information needs throughout the emergency care process. Participants gave the system a high average score of 86.8, noting that it enhances continuity of care and aids in making more informed clinical decisions. Often, in high-stress conditions and work environments, especially in the emergency set-up of a developing country, managing the timeliness of patient assessment, test ordering, triaging, and initiating management protocols becomes challenging. Having technological support for patient data on hospital premises is a boon in these demanding situations where a surge in patient flow could be anticipated. This calls for continuous support from the hospital administration, finance, and the information technology departments.^[6]

The third important finding was the inability of the HIS to generate tables and graphs that may be very helpful in understanding the trend of patients’ parameters and thus beneficial in interpreting results. Data visualization involves the use of visual formats–such as charts, graphs, diagrams, and images–to present information clearly and effectively.^[17] In healthcare, these tools help professionals interpret historical and current data while also forecasting future trends. Visualization simplifies the recognition of patterns, anomalies, and trends within large datasets, making complex information easier to understand. It is especially valuable in clinical and public health settings, where timely and accurate decision-making is essential. By converting raw data into visual formats, healthcare systems can enhance their ability to draw meaningful insights quickly.^[17]

Mathews et al.^[18] surveyed LIS users at hospitals across the United States. Participants were requested to evaluate the ease of completing 24 routine tasks using the LIS. In addition, they provided feedback on the features they appreciated and those they found challenging, offering valuable insights into the system’s perceived usability. The results of this study indicate that the overall usability of LISs could be improved.^[18] A cross-sectional descriptive study conducted by RezaeiHachesu et al.^[19] in 2015 evaluated the usability of RISs used in 3 hospitals in Tabriz City. The study concluded that the overall usability of RISs among the evaluated population averaged 65.41%, based on the assessment of 190 out of 291 components aligned with Nielsen’s 13 usability principles. In addition, usability issues were identified in 26.35% of the evaluated components.^[19]

CONCLUSIONS

The purpose of this questionnaire-based study was to evaluate the usability of the current electronic health information system in the emergency room. Features of the current HIS include assisted inpatient care, facilitated quick and simple access to laboratory and radiological reports, and assisted in the making of informed clinical decisions. It underlined the necessity of giving newly recruited residents ongoing induction training on the patient care software. To enhance patient outcomes, a regular and ongoing evaluation of the information system supporting critical clinical decisions should be promoted. With the backing of the stakeholders, objectively determining the advantages and disadvantages of the current HIS can improve the process in an emergency.