eSignout
Business
problem
Every hospital struggles to ensure good coordination of care among
all the people involved in the care of each patient. Teaching hospitals
add more complexity with medical students, interns and residents.
Our medical and psychiatric residents and interns documented workflow
and communicated tasks with Word documents in shared folders. We
needed a better "sign-out" process (the hand-off from
one person/shift to the next) to reduce the potential for medically
important errors.
Defining
the project
Beginning with the first discussion, we set some basic assumptions
about the project to try to avoid scope
creep:
- eSignout
would be an interim solution and
would be discarded once an inpatient electronic medical record
(EMR) system was implemented. We were just beginning the planning
process for an inpatient EMR, and it was critical that eSignout
not be a distraction from that effort.
- eSignout
would not be part
of the medical record. Certain documents could be printed
from eSignout, signed and placed in the paper record, but eSignout
itself would only be a workbook.
- Goals
- Enhance quality of care by
facilitating communication among all members of a patient's
care team.
- Streamline workflow for residents/interns.
- Clarify the medication reconciliation
process from admission to discharge.
- Objectives
- Role-based views for all members
of a care team, including attending physician, primary and
covering residents, primary and covering interns, medical
student, nurse, case manager, pharmacist, nutritionist, social
worker, primary care physician - any appropriate member of
a patient's care team.
- Automated feeds from clinical
systems to provide patient demographics (including insurance,
language, code status, PCP, etc.), allergies, current medications,
and scheduled outpatient appointments.
- Forms to capture current notes,
assessment and plan, medical history, studies and tests, task
list, care management, and discharge planning.
- Printer-formatted output including:
house officer sign-out, admission and daily progress notes,
care management report and task lists.
- Create process of patient-centered
discharge that includes medication reconciliation,
multidisciplinary instructions and follow up appointments.
The printed discharge materials should be written for an appropriate
reading level and translated into the primary languages of
our patient population.
- No
additional resources
would be available for user training or implementation, so there
must be a self-sustaining process for training and implementation.
Faster
data
Although we already had near-real time admission/discharge/transfer
(ADT) data,
medications and allergies were only updated in the data warehouse
daily. We developed an automated process to pull meds and allergies
every few minutes. We chose not to display lab test results, partly
because of the difficulties with ensuring CAP
compliance and partly because lab data was much more time-sensitive
and our updates would never be truly real-time.
Security
Permissions for eSignout are inferred rather than specifically granted.
In other words, if a person in a specific job role (such as resident
or attending or primary care provider) already has access to patient
data in Meditech or Epic, permissions are automatically granted
in eSignout, customized for that person's job role.
To ensure
that the current user is the same person who is currently logged into
that computer, each eSignout user must input their network password.
The username for the currently-logged-in user (obtained using NTLM)
and password are then validated with Active
Directory.
Getting
started
First-time users must complete a very simple "quiz." This
quiz is really more of a training mechanism than a test (click the
image below to see the entire quiz):

[Click
the image above to see the full size image]
The
application
eSignout is designed with navigation controls on left and right
sides and context-sensitive data in the center
(image below) much like the chronic
disease registries.

[Click
the image above to see the full size image]
Left
side navigation
On the left side of the screen, the Signout
tab is the default screen for authorized providers, defaulting
to the most recently-saved filters.
Patient
filters
provide a "sticky" way to automatically select patients
for each provider (image below):

The
Help tab describes the roles and responsibilities
of providers using eSignout (image below):

[Click
the image above to see the full size image]
The
System Maintenance tab provides, among
other things, a tool to edit "plain-language" terms for
various abbreviations (shown below). These terms are used in reports,
especially those designed for patients.

[Click
the image above to see the full size image]
Right
side controls
Once a patient is selected, the right activity panel comes into
play. Blue buttons offer screens with different slices of data for
the selected patient. White buttons open tools and forms. Working
down the list of blue buttons, the first is Care
Team (shown below), which displays the current team of providers
who are assigned to a patient and provides worksheet entry options
to edit the selected providers.

[Click
the image above to see the full size image]
Current
Notes
(shown below) allows providers to enter post-admission updates to
the patient's subjective condition, such as blood pressure, pulse
and temperature, and includes a section to document patient concerns.
This information is printed in the Intern
Progress Note Report.

[Click
the image above to see the full size image]
Assessment
and Plan
(shown below) is used at admission to document initial condition
and treatment plan, as well as for ongoing updates by interns/residents
during the patient's stay. Interns use their section to document
patient condition. Residents use the Signout section to provide
directions for cross-coverage providers and add to interns' admission
findings.

[Click
the image above to see the full size image]
Past
Medical History
(shown below) is a worksheet used to define:
- history
of present illness
- resuscitation
instructions
-
social and family histories
- review
of systems

[Click
the image above to see the full size image]
Studies
and Tests
(shown below) allows interns and residents to list any tests that
will be performed.

[Click
the image above to see the full size image]
Medications
has three sections, each of which can be expanded or collapsed (shown
below).

[Click
the image above to see the full size image]
The
first section (shown below) contains the pre-admission
medications as reported by patient, family and/or Epic outpatient
EMR. These medications may be continued or stopped as shown. This
information is used to create the pre-admission order form which
is faxed to the hospital pharmacy.

[Click
the image above to see the full size image]
The
middle section (shown below) shows current
medications as pulled from Meditech.

[Click
the image above to see the full size image]
The
bottom section (shown below) is a discharge
worklist to help with medication reconciliation, showing
a combined list of pre-admit and current medications.

[Click
the image above to see the full size image]
Clicking
the Review button displays a consolidated
view of the discharge medication worklist (shown below) as an additional
aid in medication reconciliation.

[Click
the image above to see the full size image]
Moving
to the next slice of eSignout data, Task List
(shown below) provides a way to track tasks awaiting completion
and the responsible individual. Information from the task list is
displayed on the Task
Report.

[Click
the image above to see the full size image]
Case
management and social work
(shown below) is used by the care management department.

[Click
the image above to see the full size image]
The
Discharge worksheet (shown below) is
used to document in layman's terms
-
the nature of the patient's stay,
- discharge
medications and instructions regarding diet, physical therapy
and social work support.
This
information is displayed in the Discharge
Instructions Report.

[Click
the image above to see the full size image]
Attendings
(shown below) is a worksheet used by attending physicians, keeping
their notes separate from resident/intern notes.

[Click
the image above to see the full size image]
The
Nursing worksheet (shown below) is
the newest section of eSignout.

[Click
the image above to see the full size image]
Forms/Reports
The white report buttons on the right
side of the screen provide links to the following items:
eSignout
workflow
At
admission
- Select
patient, either by using Patient Filters or with Find Patient.
- Document patient's present illness in Past
Medical History worksheet.
- Order diagnostic tests and procedures in Studies/Tests
worksheet (interns use "progress notes" box and residents
use "Signout" box).
- Document pre-admission medications in Medications
worksheet.
- Order new medications in Medications worksheet.
- Document assessment
and plan (interns use "intern" box and residents
use "Signout" box).
During
patient stay
- Primary Intern or Primary Resident maintains care team assignments
in Care Team
list.
- Document
daily findings in Current
Notes worksheet.
- Primary Resident communicates with next shift using Signout
box in Assessment and Plan worksheet.
- Document
medication changes in Medications worksheet.
- Primary
Intern or Primary Resident lists tasks in Task
List worksheet.
At
discharge
- Assign a discharge provider in Care Team list.
- Reconcile
medications in Medications worksheet:
- Expand Discharge Worklist and classify the status of all
pre-admit meds as New, Changed, Continue or Stopped.
- Expand Current Medications and select specific meds for
transfer to Discharge Worksheet by checking Add to Worklist
box.
- Complete the Discharge
worksheet.
- Print discharge forms:
- Discharge
Instructions
- Medication
Wallet Card
- Page1 report
Outcomes
- eSignout
has gained widespread use and is valued for its ability to integrate
information, increase the efficiency of daily work in the hospital,
and facilitate communication both between care providers and with
patients and their families. Persuading providers to use eSignout
has not been a problem; to the contrary, providers have pushed
to implement eSignout at a faster pace than anyone expected.
- Most
documentation that goes into the chart is generated by eSignout.
It produces documents that are legible and include all relevant
data. The data are made available online to the primary care providers
(PCP) or covering attendings from their clinics or remotely from
home.
- Greatly
improved effectiveness of sign out process between the night and
day teams.
- Adverse
drug events are the leading preventable cause of patient injury.
eSignout is part of the effort to ensure an active process of
comparing and matching the patient's most current list of medications
with those ordered at the point of admission. We have achieved
a steady increase in all patients admitted across the enterprise
(excluding labor and delivery) with an appropriate medication
reconciliation as found by a quarterly chart review.
Lessons
learned
- In
busy clinical units, there may be times when providers are waiting
their turn to use a computer. It is tempting for the previous
user to simply log out of a clinical application and not log out
of the computer entirely, saving time for the next person. This
would create a major problem in eSignout, because intranet applications
use a homegrown single-sign-on process to avoid yet another password
(Transparent security and
permissions). We solved this by authenticating each user but
without an extra password (see Security section above).
- When
properly carried out by a committed team with a capable programmer,
rapid application development techniques can be used to fill critical
needs in patient safety in the period before a major EMR implementation
is available. However, the interface between an electronic system
and a paper-based chart must be carefully considered. When documents
are printed for the medical record, clear guidelines must be set
to limit the amount and types of handwritten changes that can
be allowed. Edits of critical information must be made on-line
so that the electronic system contains the correct and most current
data.
- The
value of the collaboration and the investment in the computer
programming for this project have far reaching implications for
the entire enterprise. This was a multidisciplinary and multi-departmental
achievement involving information technology, pharmacy, nursing,
the medical, psychiatric and surgical departments, case management,
nutrition, and quality improvement. The cross-departmental working
groups and professional allegiances developed through this project
are being leveraged for other important initiatives. What's more,
the investment in this core program can be applied and repurposed
to develop other applications for clinical use.
Posted 29 May 2008
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