System Analysis of T-SYSTEM

Because of its ability to improve the quality and delivery of health care services, the Electronic Health Record is becoming a necessity in almost every healthcare organization. The purpose of this paper is to explain the impact of having an electronic health record system in an emergency department. The current computerized system used at Suny Downstate Hospital in Brooklyn is called T-SYSTEM, and has been in operation since 2007. Documentation prior to its implementation was achieved through handwritten notes on various forms as well as through dictation by doctors. Suny Downstate Hospital had to update its system in order to meet state standards and quality core measures. The transition from paper to electronic documentation is major; while it assures many advantages, it also faces many challenges. As the author of this paper, I will be using my workplace as the unit (ED) project observed. I will also identify other healthcare professionals, such as fellow nurses who are assigned to Super User or to Preceptor positions and other multidisciplinary care providers, who assist with the system. I will also discuss the system, its benefits, contributions, deficiencies, and the challenges that the system must overcome in order to achieve its maximum potential.

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The organization of interest is the University Hospital of Brooklyn, also known as Suny Downstate Medical Center. This is a teaching hospital and is the only academic medical center providing patient care, education, research and community services for the nearly 5 million people living in Brooklyn, Queens and Staten Island. Opened in 1966, the University Hospital of Brooklyn is an 8-story, 376-bed facility in central Brooklyn. The hospital has 8 intensive care and step-down units, 12 operating rooms, an emergency services department, a diagnostic and ambulatory surgery facility, an with some 75 clinics, plus 5 satellite Health Centers and a nearby dialysis center.

As stated above, the University Hospital of Brooklyn has 3 main locations in Central Brooklyn, Long Island College Hospital and in Bay Ridge. Satellite Centers in Bedford-Stuyvesant, Midwood, Family Health Services (Lefferts Avenue), Dialysis Center (Parkside) and a Sleep Center (Flatlands and Flatbush). In terms of size and manpower, Suny Downstate Medical Center has 8,000 employees on board and is the fourth largest employer in Brooklyn. Downstate’s estimated economic impact is over $2 billion. For every dollar invested in Downstate, $12 is returned to the local community (SDMC, Facts at a Glance, 2012).

The hospital aims to become the leader among many other hospitals and schools in . The hospital also has a college with 1,751 students studying Medicine, Grad Studies, Nursing, Health Related Professions and Public Health. In addition, the hospital operates a joint Biomedical Engineering program with Brooklyn Polytech. The school has 1,049 residents training in 57 specialties that are assigned to 23 affiliated hospitals. Downstate has already become the leader in physician education, where more New York City Physicians have trained than at any other medical school. In some specialties, Downstate has trained more than half the borough’s physicians. Downstate has ranked first among New York State medical schools in the number of minority students and eighth nationally. Downstate is also the only college in Brooklyn offering the MS degree in Medical Informatics. Its mission is “to provide outstanding education of physicians, scientists, nurses and other healthcare professionals, to advance knowledge of cutting edge research and translate it into practice, to care for and improve the lives of our globally diverse communities and to foster an environment that embraces cultural diversity” (SDMC, Mission, Vision and Values, 2012).

The Suny Downstate mission is to be nationally recognized for improving people’s lives by providing excellent education for healthcare professionals, advancing research in biomedical science, healthcare and public health, and delivering the highest quality patient-centered care. The hospital values pride, professionalism, respect, innovation, diversity and excellence. With the implementation of the Electronic Medical Record system, the goal is to connect caregivers and patients in order to continue the delivery of quality care (SDMC, Mission, Vision and Values, 2012).

In an interview I conducted with Ms. Margaret G. Jackson (MA, RN, and Assistant Vice President and Chief Nursing Officer at Suny Downstate), she stated: “We at Suny Downstate are pushing aggressively towards ‘Meaningful Use.’ We would like to have the system interconnect with the other units, to make it more user friendly for other physicians to put their orders in, instead of coming down to the emergency room.” Jackson also confirmed that “our objective for meaningful use is to improve quality, safety and efficiency of both doctors and nurses; we want patient and families engaged in the care given. We hope that this will improve care coordination and most importantly, ensure privacy and security for personal health information” (M. Jackson, personal interview, November 26, 2012).

To this end, Suny Downstate has hired Vickie Small, MS, RN, as the manager of nursing informatics who directs and oversees all technological development at Suny Downstate and all its affiliates. She has been with the hospital for 7 years and began her nursing career in the emergency room. She was also one of the key persons involved with the implementation of T-SYSTEM back in 2007, and was initially appointed to the role of project manager. Since that time she has been promoted to the managerial position throughout the adjustment period (V. Small, personal interview, November 26, 2012).

Throughout the interview with Ms. Small, she pointed out how challenging it was to get the staff on board, though today she is proud to see how far they have come. She noted that she was the direct link between the nurses and the T-SYSTEM team on-site to make sure the system was more nurse friendly. This “direct link” was important, as Ms. Small knew it was a system designed not by nurses but by emergency room doctors. Ms. Small also spoke about how most of the senior nurses found it very difficult to “let go” the papers and would hoard them in their lockers and chart on them and then put them in the chart. As stated by Ms. Small, “it was a difficult adjustment period, but we definitely made it.”

Basic Needs Assessment

T-SYSTEM has been utilized at Suny Downstate Medical emergency department since 2007. The aim of its implementation is to facilitate better, safer patient care, boost workflow efficiencies and maximize revenues (T-SYSTEM, About Us, 2012). Since its implementation, the system has been upgraded three times to enhance communication and effective coordinated care among all multidisciplinary members involved. Members involved are nurse manager, assistant nurse manager, registered nurses, nursing assistants, physician assistants, nurse practitioners, unit clerks, pharmacy and the radiology department that includes X-ray, CT and MRI personnel.

The emergency room layout starts with one nurse tech/nurse assistant who is stationed outside in the waiting room just to take the vital signs of the patients before they enter the actual triage area. This nursing assistant has one Computer on Wheels (COW) assigned to him/her. Inside the triage area the nurse is assigned a desk top. The registrars have 3 desk tops and 1 desk top for the Pediatric registration personnel. The Fast track area holds a capacity of 11 patients, and has 2 desk tops for the doctors and 2 COWS for the physician assistants and 1 COW for the nurse.

Inside the Pediatric area which holds 11 patients, has 5 desk tops for the doctors, 3 COWS for nurses and 1 desk top for the pediatric triage nurse. In the adult section of the emergency room, which holds a capacity of 37 patients, and 45 on an extremely busy day, has two nursing stations. In Nursing Station B, there are 3 desk tops for physicians, 4 laptops (affixed to the counter tops to prevent theft) that are also for the doctors, 2 desk tops for the clerks, and 2 COWS for the charge nurse and the ambulance triage nurse. Furthermore, there is 1 COW for the resuscitation room nurse, 1 COW for the admitting nurse, and 5 more COWS for the rest of the nurses working in the assigned area of the emergency room. On the ramp of the ambulance bay area, there are also 5 other non-working COWS, which are, however, tested by the IT department frequently.

Initially, when the system was implemented, it was met with a lot of resistance from the nursing staff. Of course, with any new technology, it is typically the novice users that will emphasize stress and anxiety. At the time of implementation, many of the staff, especially the senior nurses, were not computer literate and were reluctant to use the computer as their primary mode of documentation. There were many questions and some nurses would become upset or angry as a result of not knowing where to find a certain piece of information to complete their documentation.


T-SYSTEM uses its own software and is PC based. Citrix is also used along with the system which is a software solution that enables the safety and security of the system. According to Ms. Small, the server for the T-SYSTEM is located in Massachusetts. The go-live date was set for one month in advance while preparations such as training nurses, doctors and all others was performed in two hour sessions arranged by the director of nursing for the emergency room and the medical director for doctors. At the end of the training session, a quiz would follow as a form of evaluation.

During the implementation phase, T-SYSTEM had technicians that came all the way from Texas to assist with any questions or technical problems. They were on site for at least three weeks. Their main purpose also was to maintain the system to ensure a solid performance. Both nurses and doctors were assigned the role of “super user” and were stationed throughout the different areas of the emergency room to provide their peers with needed support. As “super users,” they were expected to be cheerleaders and display positive attitudes in order to assist in a smoother transition. They were considered very proactive and had an understanding of how to best address issues that were posed during the adjustment period. There were two doctors and two nurses for both day and night shift.

Growth, Challenges and Drawbacks

The hospital has expansion plans not only for other departments but also for the emergency department beginning in 2014 (G. Jackson, personal interview, November 26, 2012). With the influx of patients, the department seems smaller and smaller each day. There are two different types of COWS now: some have internet access and some do not, so there is always a minor dispute among nurses in the mornings as they try to get the computers with internet access. In terms of ergonomics (always a big issue for both nurses and doctors), the chairs are reported to be uncomfortable (some have a back rest while others do not); some nurses feel that the stools provided with wheels are not safe to be in the department; and doctors tend to commonly complain that their work space now feels cluttered.

The need for more informatics nurses has been raised from time to time. During an interview with some of the nurses, they stated that even though a survey was performed a month after implementation and the system has been updated many times, they feel as though it is still not as nurse-friendly as it should be. Gayle B., RN, stated it is not a good system, “but we were just happy to get something” (G. B., personal interview, December 2, 2012).

From the finance department, Gerald E. stated “the hospital has lost millions due to documentation in the system; this is because the charge capture for the physician is not the same for the nurses — which has, of course, changed the way we now document. It’s a big problem that was not sighted for quite some time, but was picked up last year.” One example of this problem is that there is a charge for the vaginal exam performed by the physician but not for the plastic speculum handed by the nurse: “This is because a plastic speculum is not an item available for us in our documentation. In other words, what the doctors have for their billing is readily accessible for them but not for us nurses” (G. E., personal interview, November 19, 2012).

One possible solution to such a problem could be to have these and other items that are not charged encrypted into the Pyxis system.

A problem that has been posed this year by Cecile B., RN, is that when patients are admitted, the emergency physicians are no longer caring for these patients but will do so only if it is an emergency. In fact, it is the admitting team that is now responsible for this patient. However, due to the fact that they did not have access to T-SYSTEM, their orders were on paper and once again these orders needed to be transcribed prior to sending the patients to the floor. “This was a very time consuming because as the primary nurse you’re dealing with new patients and admitted patients at the same time which could cause more error and more harm for patients” (C. B., personal interview, November 19, 2012).

The solution to this problem was implemented in May 2012 and is called Health Bridge. Health Bridge integrates the system that nurses on the other units use, which allows the admitting doctors and residents to now access the admitted patients’ charts from anywhere in the hospital. These doctors are then able to place orders and print labels down into the emergency room and to have blood work performed on these admitted patients. According to Cheryl Fraser, MS, RN, the benefit to this integration is that it enhances patient continuity of care (C. Fraser, personal interview, November 19, 2012). However, the problem still exists for nurses in the emergency room because it is very difficult to manage new patients on one system, while trying to give care to the admitted patients on another system. This is also because one system shuts you out quicker than the other and running more than one system tends to slow down the computer. The go-live date for this system was set for two weeks and had raised speculations concerning administration’s eagerness to start this system.

An ongoing problem that I’ve seen that exists and one that I keep inquiring about is that when you return to work the day after taking care of a patient and that particular patient, who may still be in the department is on your new list of patients, the system has no prompt to alert you to say, “This is patient MG; is this whom you want to document on?” According to Ms. Small, this is an ongoing problem that we are in the process of amending (V. Small, personal interview, November 26, 2012).

According to Gayle B., RN, doctors can go back and change their charging — but nurses do not have access to do that. Resources for such access were available for one week, and of course there was a lot of chaos at the time. Some nurses also thought they needed more time to learn the system: “Because they felt they were rushed into learning, they did not find some of their resources to be very helpful” (G. B., personal interview, December 2, 2012).

Meaningful Use and EMR Implementation

For the attestation process, T-SYSTEM Meaningful Use is available to assist nurses in tracking attestation progress. This process is facilitated by the system’s ability to locate and transfer patient information from the Emergency Department. Meaningful Use is meant to help departments interact with information previously isolate in one department. With this aspect of T-SYSTEM, patient data is theoretically more accessible to nurses so that they might comply more readily with guidelines.

Because information technology is constantly evolving, electronic medical records (EMR) and EMR implementation must stay abreast of current developments. Staying abreast of the latest developments is helpful in improving hospital efficiency. However, budgetary concerns as well as the practicality of project planning and development play a large part in allowing a hospital staff to keep abreast of all updates within their field of information technology. To this end, it is recommended that project teams work in conjunction with physician heads to make the required decisions concerning the implementation of EMR.


The Health Information Technology for Economic and Clinical Health (HITECH) Acct, passed in 2009, was enacted in order to address the issues of meaningful use in the healthcare information technology realm. HITECH has several consequences, both economical and practical: for instance, “the nation’s employers can expect a 9% jump in medical costs in 2011” as costs for EMR implementation are raised due to HITECH (Monegain, 2010). Hospitals are expected to receive bonuses and/or penalties depending upon their compliance with HITECH regulations. The implementation and usage of IT is now essentially become mandatory in the healthcare field.

HITECH may be seen as a positive piece of legislation for IT firms, but for the nursing and doctor staff at Suny, it appears to be shouldered as one more cross in the evolution of healthcare services. From cluttered works stations to difficult, of documentation, Suny staff members feel the effects of HITECH in different ways. Regardless of their overall thoughts and feelings, however, T-SYSTEM is here to stay — at least for the time being, which is to say for as long as the promise of better quality service is believed to come through information technology enhancements.


Increased spending on EMR implementation is required to meet state standards (HITECH), results in increased productivity, new technology, and is deemed necessary to maintain a competitive edge. EMRs may prove to be an essential tool for the future of healthcare, and they have certainly demonstrated improved patient outcomes and increased patient satisfaction (M. Jackson, personal interview, November 26, 2012). From the American Recovery and Reinvestment/Health Information Technology for Economic and Clinical Health (ARRA/HITECH) Act of 2009, hospitals have seen an increase in reimbursement from the Federal government as an incentive to become “meaningful users” of EMRs.

In addition, in spite of all complaints, nurses are becoming increasingly comfortable with the use of technology; hopefully, as time goes on, the workflow of nurses will become much easier as each new system is implemented and understood. Maybe one day it will be a nurse informationist that will invent a system that speaks the language of nursing and make the collaboration among doctors, IT experts and nurses more unified.

Reference List

B., C. (2012, November 19). Personal interview.

B., G. (2012, December 2). Personal interview.

E., G. (2012, November 19). Personal interview.

Fraser, C. (2012, November 19). Personal interview.

Jackson, M. (2012, November 26). Personal interview.

Monegain, B. (2010). HITECH Act ‘lit a fir’ under health systems. Healthcare IT News.

Retrieved from

SDMC. (2012). Facts at a Glance. Retrieved from

SDMC. (2012). Mission, Vision and Values. Retrieved from

Small, V. (2012, November 26). Personal interview.

T-SYSTEM. (2012). About Us. Retrieved from