Workflow Improvement and Increased MD Satisfaction After Integration of Sign-out into the EMR

1. Workflow Improvement and Increased MD Satisfaction After Integration of Sign-out into the EMR Jon Bernstein MD, PhD1,2 Dan Imler, MD1,2 Christopher Longhurst MD, MS1,2 1Department of Pediatrics, Stanford University School of Medicine 2Lucile Packard Children’s Hospital at Stanford I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

2. QSHC, 2005 “Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.”

3. Outline • Integration of sign-out documents into the EMR • Background • Solution • Outcomes • Future work

4. A teaching hospital associated with Stanford SOM Pediatric and Obstetric Care Opened in 1991 Statistics, 2006 13k Discharges 106k Clinic visits 264 Active Beds 40%+ critical care patients “Top 10 Children’s Hospital”, US News & World Report, 2007 Lucile Packard Children’s Hospital

5. State of Signout at LPCH 1/2005 • Sign-out methods highly variable • Exclusively verbal sign-out • Index card handoff • Word documents • Email • Drawbacks: • Redundant entry of data already in the HIS • Prone to transcription error, information aging • Poor accessibility of information • Risk of HIPAA noncompliance

6. NEJM, June 2003 “Computerized sign-out procedures should be adopted that are universally applicable within a particular specialty. Such a system is likely to reduce medication errors; minimize handwritten information, which can be difficult to interpret; and improve the continuity of care.”

7. JHIM, Fall 2005 “The integrated sign-out report gives physicians needed information, most of which already exists in the hospital’s information system. Physician acceptance and even endorsement of CPOE systems may be achieved by providing tools and reports that improve their efficiency and workflow.”

8. Easy to generate from user’s existing patient lists in HIS Area for handwritten notes Sign-out Report (May 2006)

9. Signout Report – Details Weight and allergies (data documented by NURSING) Demographics, admission date, hospital day (calculated from date of admission), attending, and PCP (data documented by REGISTRATION staff) Signout information with date, time, and author name (data documented by HOUSESTAFF) Medications orders (data entered by PHARMACY) Recent CBC and BMP results in fishbone format (automatically pulled from LABORATORY)

10. Signout Form

11. Qualitative Outcomes • With integration, decreased use of freestanding sign-out documents.This supports a model of recording information on patients only when appropriate. • Data reusability improves convenience • Reduced transcription of data in HIS • Data transfers with patient in the hospital (e.g. ICU  to floor transfer) • Data pulls forward across hospital encounters (50% freq flyers!) • Historical documents available for review (e.g. for creating d/c summary) • Improved accessibility to data supports communication • Consulting services and attending physicians can access sign-out information • Interdisciplinary (Nursing, RT, case management, etc.) have access to information

12. Quantitative Outcomes • Daily usage statistics generated from HIS • By Unit • By Practitioner Role • Pre-post survey of pediatric residents (n=60) • Month 1 • Month 6

13. Usage of Signout Form

14. Resident Reported Patterns of Usage p<.001 Day to Night, p<0.05 Night to Day X2

15. Satisfaction with Primary Sign-out Tool p<.01, X2

16. Resident Perception of Decrease in Redundant Data Entry p<.01, X2

17. Resident Perceptions of Patterns of Communication

18. Summary of Findings • Usage data revealed • Usage increased rapidly and leveled off • Training was important to adoption • Tipping point effect • Resident survey data revealed • Improved satisfaction • Perception of improved workflow • Perception of improved communication