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
  1. Enhance quality of care by facilitating communication among all members of a patient's care team.
  2. Streamline workflow for residents/interns.
  3. Clarify the medication reconciliation process from admission to discharge.
• Objectives
  1. 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.
  2. Automated feeds from clinical systems to provide patient demographics (including insurance, language, code status, PCP, etc.), allergies, current medications, and scheduled outpatient appointments.
  3. Forms to capture current notes, assessment and plan, medical history, studies and tests, task list, care management, and discharge planning.
  4. Printer-formatted output including: house officer sign-out, admission and daily progress notes, care management report and task lists.
  5. 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.

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):

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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.

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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):

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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.

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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.

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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.

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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.

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Past Medical History (shown below) is a worksheet used to define:

• history of present illness
• resuscitation instructions
• social and family histories
• review of systems

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Studies and Tests (shown below) allows interns and residents to list any tests that will be performed.

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Medications has three sections, each of which can be expanded or collapsed (shown below).

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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.

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The middle section (shown below) shows current medications as pulled from Meditech.

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The bottom section (shown below) is a discharge worklist to help with medication reconciliation, showing a combined list of pre-admit and current medications.

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Clicking the Review button displays a consolidated view of the discharge medication worklist (shown below) as an additional aid in medication reconciliation.

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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.

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Case management and social work (shown below) is used by the care management department.

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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.

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Attendings (shown below) is a worksheet used by attending physicians, keeping their notes separate from resident/intern notes.

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The Nursing worksheet (shown below) is the newest section of eSignout.

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Forms/Reports
The white report buttons on the right side of the screen provide links to the following items:

• Resident Signout report — Report using information from Assessment and Plan, Medications and Task List worksheets.
• Intern Signout report — Report using information from same sources as Resident Signout report (above).
• Task report — Report using information from Task List worksheet.
• Intern Progress Note** — Report using information from Current Notes, Assessment and Plan, and Medications worksheets.
• ICU Progress Note** — ICU-level report using information from Assessment and Plan, Medications and Studies/Tests worksheets.
• Admission Note (H&P)** — Admissions report using information from Current Notes, Past Medical History, Assessment and Plan, Medications, and Studies/Tests worksheets.
  • page 1
  • page 2
  • page 3
  • page 4
• Resident Addendum** — Report using information from Assessment and Plan to amend intern's findings.
• Attending Progress Note** — Report using information input by attending physicians.
• Attending's Window — Report showing the interns' progress notes for that attending physician's patients.
• Page1 — Standard-format report using information from Discharge worksheet, produced if patient is transferred to another site of care.
• Discharge Instructions — Patient-friendly discharge summary report using information from Discharge worksheet.
• Medication Wallet Card — Patient-friendly, easy to carry medication report using information from Medications worksheet.

  ** This report, when printed and signed by the clinician, may be added to the patient's (paper) chart as part of their medical record.

eSignout workflow

At admission

During patient stay

At discharge

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