Introduction: Recently, several technologies have been developed for being used in the field of geriatric emergency medicine. As a large number of elderly patients visit emergency departments, the use of health information technology in this department can help to improve patient care and control the outcome of diseases. The present study aimed to identify opportunities for using various health information technologies for elderly care in the emergency department.
Methods: This qualitative study was conducted in 2020. The participants included geriatricians, geriatric nurses, emergency medicine specialists, and nurses who worked in the emergency department. In total, 33 semi-structured interviews were conducted, and data were analyzed by using framework analysis method and MAXQDA software.
Results: The findings of the qualitative study included four main themes, nine subthemes, and 20 categories. The main themes were the common process of elderly care in the emergency departments, data required for elderly care in the emergency departments, the elderly treatment team, and current information technologies used in the emergency departments for elderly care. Overall, the results showed that there was no specific workflow for elderly care in the emergency departments; the great workload of this department prevents the clinicians to conduct cognitive and functional assessments; geriatricians were not involved in the care process; and none of the current information systems were designed specifically for elderly patients. It seems that using specific heath information technology for elderly care in the emergency department can help to overcome current challenges.
Conclusion: Identifying opportunities for using health information technologies for geriatric patients in the emergency department can lead to better use of financial, physical, and human resources, and improve staff performance. These systems can be designed and used for different purposes such as reducing work load, readmissions, and hospitalization. Improving access to data and better collaboration between different specialties are other benefits of using these systems. However, more research is required to evaluate the effectiveness of technology in this area.
Keywords: health information technology, medical informatics, emergency department, elderly
As the number of elderly people is increasing in different countries, hospital emergency departments have been faced with more challenges than other departments in providing healthcare services for this age group. However, current emergency care facilities may not meet the requirements of the elderly.1,2 In emergency departments, the elderly usually have the longest waiting time for treatment and discharge, and the difficulty of obtaining a history due to their hearing and mental impairment makes the evaluation of elderly patients complicated and time-consuming.3 On the other hand, the number of admissions of the elderly in the emergency department is increasing every year.4 For example, in some countries, such as Turkey and the United States, more than 24 percent of emergency patients are the elderly,5-9 and they spend more time in emergency departments than other age groups.10,11 Therefore, emergency care processes need to be improved for this group of patients. The lack of care optimization for the elderly can lead to adverse outcomes of care and increase readmission, mortality, and morbity.12,13 It is notable that, according to the World Health Organization (WHO), indviduals who are 65 years old or older are considered elderly from a chronological perspective.14
As the field of geriatric emergency medicine evolves, the use of various health information technologies (HIT) in this area has been found of particular importance.15 The application of health information technology in geriatric emergency medicine can be useful in various aspects, such as prevention, care support, and process management mainly by providing adequate data at the point of care.16-18 Moreover, the availability of information—especially via information technologies—can help clinicians to make better decisions at the right time.19 Generally speaking, health information technology includes a variety of Information and Communication Technologies (ICT) that are used to collect, store, transmit, and display patient data.20 A wide range of products and services such as electronic health records (EHRs), telehealth, mobile health (mHealth), remote monitoring tools (telemonitoring tools), assistive technology, and sensors are some of the examples of heath information technologies.21,22
Recently, several technologies have been developed for use in the field of geriatric emergency medicine.23 For example, the use of a clinical decision support system (CDSS) has helped to improve pain management. This system was designed based on the guidelines for the prompt management of geriatric pain and is aimed to enhance physician awareness about geriatric pain assessment and treatment.24 Vital signs monitoring systems have helped to reduce waiting time and mortality, accelerate diagnosis, and improve health outcomes by providing adequate data at the point of care.25 The use of computerized physician order entry (CPOE) and EHRs in emergency departments have reduced the number of radiographic and laboratory test requests and saved costs by preventing repetitive diagnostic procedures.26,27 Nurses can use different methods of electronic documentation for elderly patients to reduce errors and overlaps in the documentation.28 Telemedicine is another widely used technology that has the potential to facilitate care processes in geriatric emergency medicine.29 To date, the mentioned systems have been used for different groups of patients, and there is a large literature support for their effectiveness. However, few studies have focused on the use of health information technologies in geriatric emergency medicine, and in particular in emergency departments. As the requirements of elderly patients can be different from other age groups who visit emergency departments, the purpose of this study was to identify the opportunities for using various health information technologies for elderly patients in emergency departments.
This qualitative study was conducted in 2020 and, before conducting the research, ethics approval was obtained (IR.IUMS.FMD.REC 1396.9323563001).
The participants were selected using the maximum variation purposive sampling method and included geriatricians and geriatric nurses who worked either in the medical universities or geriatric clinics, and emergency medicine specialists and emergency department nurses who worked in emergency departments. A criteria of having at least three years of work experience in geriatric medicine, emergency medicine, or geriatric emergency medicine was considered for all participants.
The settings of the study were four medical universities (Tehran, Shahid Beheshti, the Iran University of Medical Sciences, and the University of Social Welfare and Rehabilitation Sciences) that had geriatric medicine or geriatric nursing departments, and three hospitals affiliated with the medical universities in which the number of ED visits per month was higher than other emergency departments. These hospitals were responsible for providing patients with the secondary care services.
Data were collected through in-depth, semi-structured interviews with 33 informed individuals in January 2020 through February 2020. Interviews continued until data saturation was reached. Prior to the interviews, an interview guide was developed based on literature review30-35 and consisted of 10 open-ended questions (Appendix I). The questions were related to the current clinical pathway for elderly patients in emergency departments, current challenges, differences between this group of patients and other emergency department patients, and current status of, and opportunities for, using heath information technologies for geriatric patients in the emergency departments. To refine the questions of the interview guide, initially, three interviews were conducted, and problems in terms of ambiguity of questions in the interview guide were identified and corrected for subsequent interviews. The validity of the interview guide was assessed by six experts in the field of geriatrics, emergency medicine, and geriatric nursing.
To collect data, potential participants were contacted by one of the researchers (GS), and a convenient time was proposed by those who agreed to take part in the interview. All interviews were conducted in the workplace of the interviewees by one of the researchers (GS), and in a crowded environment, such as an emergency department, a quiet room was selected and interviews were conducted in that room. All of the interviewees signed a consent form before conducting the interviews; however, they could leave the interview whenever they needed. The interviewees were also provided with adequate information about the research objectives and the contact information of the researchers. The interviews were digitally recorded with the interviewee’s permission, and notes were taken whenever it was necessary.
In order to analyze data, the thematic analysis method and MAXQDA software (version 10) were used. In this method, themes are identified, organized, described, and reported. The focus of this method is on the inductive rather than deductive coding and provides a flexible approach that can be modified for different studies.36
In this study, the interviews were transcribed verbatim and studied by one of the researchers (GS) several times. After getting familiar with the content, the researcher (GS) identified the key concepts, coded, and adjusted them based on the thematic framework. To codify the interviews, first the common concepts were identified and then the main categories and subthemes and themes were determined. The results were reviewed by other researchers, (HA) and (MH), to avoid inconsistency in reporting the results and misinterpretation. Finally, a summary of the results were sent to the interviewees to check the credibility of the findings and all of them approved the content.
In this study, 33 clinicians participated in the interviews, and the average time of the interviews was 50 minutes. Table 1 shows the demographic characteristics of the participants.
As Table 1 shows, about half of the participants were men (n=17, 51.5%), and the highest frequency (n=13, 39.4%) was related to the age group of 40-49 years old. Regarding the educational level, specialists had the highest frequency (n=18, 54.5%). Their specialties included emergency medicine and geriatrics.
Overall, four main themes, nine subthemes, and 20 categories emerged from data analysis. The themes included the common processes for elderly care in the emergency departments, required data for elderly care in the emergency departments, the elderly care team, and the current information technologies used for elderly care in this department (Table 2). Each of the themes, subthemes, and categories are described below in detail. It is notable that to respect the confidentiality issues, we de-identified the interviewees’ personal information and used the letter “P,” which indicates a participating interviewee and the number following that indicates the specific interviewee who provided the quote.
Theme 1: Common Processes of Elderly Care in the Emergency Departments
Elderly care in emergency departments is different from caring for young patients, and more time is required to assess various aspects of their health status. Most of the interviewees noted that the emergency department of a hospital is divided into different sections, including triage, resuscitation, green, yellow, and orange units. The names of these units may vary slightly depending on the physical space of the emergency departments, but all emergency departments cover five levels of care for patients. It is notable that these colors are used based on the standard triage color coding, and they are used in all emergency departments. According to the interviewees, the severity of the disease and the urgency of receiving treatment were determined in the triage unit for every patient who entered to the emergency department. Then, the patient was transferred to the relevant unit according to the triage score.
The green unit included outpatients who did not need special counseling and would be discharged in less than six hours. The yellow unit included patients who were clinically stable and waiting to be transferred to inpatient or intensive care units. The orange unit included patients with heart and respiratory problems or patients who needed isolation or relaxation. Patients with a high risk of cardiac arrest or poor general condition were also taken directly from the triage to cardiopulmonary resuscitation unit (P 21).
According to the interviewees, there was apparently no specific workflow for the elderly care in the emergency departments, and this group of patients was admitted to the emergency department just like other people. Regarding the work processes associated with the elderly care, one of the nurses who worked in the emergency department stated: “… We do not consider any specific workflow for the elderly and do not have any separate section for them. The patient who enters is triaged and the triage level (from one to five) is determined, then the patient is referred to the appropriate unit for his/her condition …” (P 31).
Most of the interviewees believed that, due to several reasons, such as the availability and cheap health care services, the number of emergency patients is high in general, and one of the main groups of emergency patients is the elderly. It seems that more than half of the emergency patients are the elderly and brought to the emergency departments for various reasons such as fall, lung infection, kidney infection, heart attack, stroke, and sometimes accident. Another reason for the large number of elderly referrals to emergency departments is receiving insufficient care at home along with low public awareness about the proper use of healthcare resources and facilities, which leads to unnecessary referrals of the elderly to the emergency departments. In this regard, one of the emergency medicine specialists stated: “… If we look closely, we find that about 50 to 60 percent of the elderly who refer to the emergency room do not need emergency care services, but they are just old and suffer from chronic conditions …” (P10).
According to some of the interviewees, the proper use of the referral systems, in particular via a family physician, can prevent the elderly from unnecessary referrals to the emergency department. Moreover, it is possible to prevent acute conditions and reduce the number of referrals to emergency departments just by modifying and applying small changes to the elderly life style. Such a workload can also be managed by using different types of health information technologies like telemedicine.
According to the interviewees, the method of care in the emergency department is disease-based, and the elderly, like other patients in this department, receive healthcare services based on the severity and urgency of their disease. According to the interviewees, all patients are categorized according to the triage guidelines, and emergency severity index (ESI), which cover all age groups, are used for them (P 20).
As the elderly patients may not be able to move or get out of the bed on their own, clinicians are required to obtain a sufficient history of the cognitive and functional status of them. However, the nature of the emergency department processes prevents any time-consuming operations. Therefore, it is necessary to conduct a quick clinical assessment of the elderly in a concise manner and based on the priorities in the emergency room. The rest of the additional actions should be done after the patient’s condition is stabilized (P 3). This process can be facilitated by using health information technologies, such as clinical decision support systems.
The majority of the interviewees stated that a lack of trained staff in the field of geriatric emergency medicine, a large workload, and the time limit to provide the elderly or their companions with discharge recommendations may cause many unnecessary visits to the emergency department in future. The discharge recommendations, which were given to the patient or their companion, were in two sheets like a checklist. The interviewees believed that the continuation of care is one of the important factors that should be taken into account for elderly patients. Otherwise, any deficiency in treatment will lead to the elderly referral to the emergency department. They need to be communicated properly to follow their treatment and medication adherence, for example via telemedicine services.
Theme 2: Data Required for Elderly Care in the Emergency Department
The elderly have special characteristics that are different from other age groups, and it is necessary to pay attention to their requirements in emergency departments. This theme included clinical and supportive data required for elderly care in emergency departments.
Due to the various problems that the elderly have, it is necessary to take a medical history, do screening tests, and use appropriate questionnaires to obtain adequate clinical data about them in order to facilitate their treatment process. Most of the interviewees stated that the elderly visit emergency departments for various reasons such as lung or kidney infections, heart attack, stroke, accidents, and falls. Loss of consciousness, weakness, and lethargy are common causes for these conditions. Some geriatricians believed that if the elderly refer to the emergency room for any reason, it is better to perform the necessary screenings tests for them.
Unfortunately, the characteristics of emergency departments, such as overcrowding, a large number of referrals, and staff shortage, have left few opportunities to pay attention to the screening tests of the elderly. Therefore, it seems that the presence of geriatricians in the ED can help other clinicians. These people may have sufficient time and adequate knowledge to perform necessary screening tests for the elderly and can provide a complete medical record for these patients. Although using some questionnaires, such as Activities of Daily Living (ADL), Identification of Seniors at Risk (ISAR), and Instrumental Activities of Daily Living (IADL), is very helpful to assess the health status of the elderly, it seems that completing these questionnaires depends upon the presence of geriatricians or nurses trained in geriatric emergency medicine. These people have adequate knowledge and can spend more time on patient assessment. Sometimes the use of these questionnaires can lead to identifying at-risk people as well as dysfunction syndromes before discharge, thus preventing the subsequent re-referral of the elderly to emergency departments. Obviously, collecting these data in different systems such as electronic medical records, electronic health records, and personal health records can facilitate getting access to the right information at the right time and place.
According to the interviewees, elderly patients who refer to the emergency department need supportive data about insurance coverage and self-care education in addition to medical treatment. The findings showed that, sometimes, there is no special insurance coverage for the provision of services by geriatricians. Moreover, identifying the patient’s family and the presence of the elderly patients’ companions in the emergency department are very important. In the absence of such persons, the elderly should be introduced to the welfare organizations. Some interviewees noted that volunteers can also be employed to help the elderly in the emergency departments (P1, P24), and without training, self-care education, and strong communication with the elderly family, successful treatment will not be provided (P26).
Theme 3: The Elderly Care Team
The findings showed that the elderly care team was limited to the ED clinicians, and there was no plan to add the geriatricians to this team in the emergency departments. In this regard, one of the nurses said: “… The basis of the emergency medical team is emergency medicine; if they need to consult other specialists, they will ask infection, heart, internal medicine, and other specialists in the inpatient department. We do not have geriatric medicine in the emergency room…” (P16).
It seems that geriatricians were busy with the outpatients, clinics, and nursing homes. Also, there was not a positive attitude regarding collaboration with geriatricians in the emergency departments. The interviewees believed that involving other specialties in the elderly care team depends on the positive attitudes of senior managers, organizational facilities, and financial supports. According to the interviewees, the elderly care team included the main health care providers and medical consultants.
Main Health Care Providers
The findings showed that, generally, the main healthcare providers in the emergency departments were emergency medicine specialists and nurses, and there was no specific care team for the elderly in this department. However, in an ideal situation, this team could include geriatricians, emergency medicine specialists, geriatric nurses, elderly sports specialists, geriatric nutritionists, and physiotherapists (P 8). Some of the interviewees stated that the presence of trained geriatricians and geriatric nurses in the emergency medical team as well as adequate space in the emergency department for the elderly care can help to improve health outcomes of the elderly.
According to the research findings, in case of necessity, consultants in different medical fields such as internal medicine, surgery, infectious diseases, neurology, cardiology, or other required specialties would be asked to help in elderly care. These medical consultants were either available in the inpatient or in the outpatients departments. According to some interviewees, the involvement of specialists such as physiotherapists, geriatricians, clinical pharmacists, psychiatrists, and geriatric nurses in the emergency medical team would result in better health outcomes for the elderly, but basic coordination and planning need to be considered at the higher organizational levels. In this case, even telemedicine technology can be used to facilitate collaboration between different specialties.
Theme 4: Current Information Systems Used for Elderly Care in the Emergency Departments
The results showed that in the emergency departments, information systems were used jointly for all ED patients, and there was no specific system for the elderly care. As noted by an interviewee: “…We do not have any specific health information technologies for the elderly. We have picture archiving and communication system (PACS) and hospital information system (HIS) in the emergency department or emergency department information system that can be used by all patients and are not specific to a specific age group…” (P 23).
This theme included emergency department information system and the challenges of using it and other health information systems, which are described below.
Emergency Department Information System and the Challenges of Using It
The results of the interviews showed that the emergency department information system was used as a subsystem of the hospital information system, and there was no specific information system for elderly care. Regarding access to patients' information, one of the interviewees said: “…Previous history, medications, and problems of elderly patients along with a medical history should be accessible in the hospital information system…” (P 27).
According to the results, despite the use of information systems in the emergency departments, there was no connection between the hospital information systems of different hospitals, and the lack of integration between these systems made the treatment process difficult. According to the interviewees, the accessibility of patients’ medical history and the results of previous diagnostic tests can accelerate the provision of appropriate healthcare services and reduce related costs. Error reduction as a result of the system integration and improving the completeness of patients’ records are other benefits of using emergency department information systems.
Other Health Information Systems
The interviewees believed that in order to use technology, it is necessary to provide appropriate infrastructure, and users should receive necessary training in this regard. In fact, the technology will not be very effective if it is used improperly or imposes additional workload. Most of the interviewees believed that access to a variety of technologies such as electronic health records, integrated information systems, telemedicine, electronic questionnaires, trackers, as well as clinical decision support systems would be very useful, if they are supported by senior managers. In this regard, one of the geriatricians noted: “… Clinical decision support systems and reminders work well to provide elderly care, and other technologies can help reduce emergency readmission …” (P 9).
Some specialists expressed their interest in electronic prescriptions and technological products such as airbag belts and trackers for the elderly, which would prevent serious injuries in case of a fall, and Alzheimer’s patients would be tracked effectively.
The interviewees believed that using all parts of the hospital information system and launching an electronic health record system would have far-reaching benefits. The picture archiving and communication system was another technology used in the emergency departments, and the emergency medical team was able to access the results of medical imaging of the elderly and other patients via computers in the emergency departments. According to the interviewees, access to this system via a wireless network could also be useful for physicians (P 31). The interviewees also stated that although there was no specific information system for the elderly in the emergency rooms, all emergency rooms were equipped with vital signs monitors for different groups of patients including the elderly.
The use of health information technologies for the elderly in emergency departments is a new approach that is used in many countries. These technologies can be applied for different purposes, such as patient care, department management, treatment, follow-up, and training.37 As the speed of diagnosis and treatment is important in emergency departments, the use of technology can help to expedite the care processes. In the present study, the opportunities for using various health information technologies for elderly care in emergency departments were investigated.
The results showed that although the care requirements of elderly patients are different from other age groups, and they are a major group of patients who visit emergency departments, there was no specific workflow for caring and providing them with appropriate emergency care services. In addition, a great part of the workload in the emergency departments was devoted to elderly care. Similarly, Lyons et al. found that, compared to other emergency department patients, elderly patients may have multiple active diseases that need to receive different types of treatments. It seems that health information technologies can be used to provide them with better emergency care services and reduce the workload. For example, electronic screening and assessment can provide an overview of the health condition of elderly patients, and clinical decision support systems can be used for these purposes to support clinical decision-making.38 There are also opportunities to continue treatment for the elderly who are discharged from emergency departments by using telemedicine technology, such as tele-follow-up services.39 However, users may experience difficulty in integrating the technology into their routine clinical practices or changes in patient care processes due to a modification of data flows and task sequences. As a result, the uptake of these systems should be aligned with clinicians’ tasks to achieve the desired outcomes. Similarly, in terms of elderly care, the context of use and key activities should be initially investigated to be able to design and use information systems efficiently.40
According to the findings, emergency department clinicians need to have access to both clinical and supportive data of all patients, especially for the elderly.41,42 This is another opportunity to use information technologies such as hospital information systems, emergency department information system, electronic health records, and personal health records to improve health care services. These technologies can also help managers and decision-makers to control adverse effects of treatments such as death, long-term stay, and frequent emergency visits of the elderly.43 Other benefits of using these systems are easy access to the current and past patient information, decreasing practice variability, and ensuring legible communication between health care providers, which can save time for them.44 However, it is important to consider data exchange standards,45 as a lack of information sharing may limit the possible benefits of using information technology in care processes.46
In terms of the elderly care team, the findings showed that medical staff in the emergency departments (physicians, nurses, etc.) and medical consultants in the hospitals were the main members of the care team. However, this team should also include geriatricians, geriatric emergency medicine specialists, geriatric nurses, geriatric nutritionists, and physiotherapists. Similarly, Devriendt et al noted that in most geriatric emergency care models, collaboration between the emergency department team and geriatricians has been highlighted to reduce the emergency department workload. These models can help to reduce unplanned readmissions, hospitalization, and health outcomes.47 To access medical consultants or geriatricians at any time and place and to expand the elderly care team, the use of technologies such as telemedicine and teleconsultation is recommended.48
The results showed that current information systems in the emergency departments included hospital information systems, emergency department information systems, vital signs monitoring systems, and picture archiving and communication systems, which were used for all patients; there was no specific information system designed or used for elderly patients. These systems facilitated multidisciplinary task management and a quick overview of patients, staff, and processes was available for the system users.49 However, according to the literature, many other information systems can be designed and implemented to support the elderly care processes in emergency department. The use of telemonitoring systems for the elderly with multiple health problems,50 asking the elderly in the emergency department to provide clinical information by using a tablet computer,51 and predicting hospital readmission for elderly patients by using machine learning algorithms52 are some examples of using information systems to facilitate screening and monitoring patients outside the emergency department, reduce the workload of this department, and improve care processes.
Limitations of the Study
With an increase in the elderly population, many emergency departments need to visit more elderly patients. This group of patients presents unique challenges to the healthcare team. However, the use of health information technology can help to improve quality of care by improving the accessibility of data and healthcare services, for example, via telemedicine. Although the current study helped to identify opportunities for using health information technology for the elderly in the emergency departments, it has some limitations.
In this study, only three emergency departments were selected, and their emergency medicine specialists and nurses were interviewed. However, these emergency departments had a high number of patient referrals per month compared to other similar settings. Moreover, the number of geriatricians and geriatric nurses was limited, as the field of geriatric medicine was relatively new in the country. We tried to include a variety of expertise and explore specialists’ opinions; however, there might be other people or specialties, such as psychologists, who may have different opinions about using health information technology for elderly patients in the emergency departments.
Moreover, as the main users of the information systems were clinicians in the emergency departments, we did not interview elderly patients or their caregivers. These people may have their own perspectives about using information technology in the emergency departments.
In this study, although a number of opportunities were identified for using health information technology in geriatric emergency medicine, the application of these technologies depends on many other contextual and organizational factors in different countries. Therefore, the feasibility and benefits of using different types of health information technologies for elderly care in the emergency departments can be investigated in different countries to address the limitations of this research.
The findings of the present study showed that there are a number of opportunities that health information technologies can be used for elderly patients in the emergency departments to improve clinical practices and quality of care. Identifying these opportunities and using the technology can also help to better use of financial, physical, and human resources and improve staff performance. These systems can be designed and used for different purposes such as reducing work load, readmissions, and hospitalization. Improving access to data and better collaboration between different specialties are other benefits of these systems. However, to implement the systems successfully, aligning the views of the key medical staff, such as emergency department specialists, nurses, geriatricians, and geriatric nurses, about using these systems is necessary. Healthcare policymakers may also benefit from getting access to high-quality reports about the elderly care processes and can use them in future planning and better management of resources. However, more research is required to evaluate the effectiveness of technology in this area.
Conflict of Interest
The authors declare that they have no conflict of interest.
This work was funded by Iran University of Medical Sciences, Tehran, Iran (IUMS/SHMIS_I/96/9323563001).
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