Here I review a tool that has profoundly changed workflow at the Hospital of The Hospital of the University of Pennsylvania. Warning: nothing here is cutting-edge from a technology standpoint, nor from design or styling standpoints. In fact, the functions our application carries out resemble an Excel table or Access database. However the implications of such a simple tool on workflow are profound.
The EMRs structure facilitates billing rather than patient care
Ideally the EMR would provide all the technology needed for efficient patient care. EMRs, however, are structured around a system of daily progress notes. Each day you start with a blank note–a workflow that resembles how we used to work with pen and paper. This creates a fragmented system of documentation, and therefore medical thinking and reasoning become fragmented too.
The use of a living document was the innovation here
What providers need is a canvas that reflects constantly-evolving hypotheses about a patient, something we can revise hundreds of times per day as new data comes in. When acquiring a new patient, the process of reading weeks of progress notes to understand a patient's hospital course is too costly. The tool contains a living document that summarizes the latest information, and is the single place to find the latest information on the plan of care. It also serves as a scratchpad where we write reminders for ourselves and our teammates. In the end, it’s a summarizing tool, a communication tool, and a workflow tool. Medical teams in hospitals across the country maintain such a tool in some form, and it’s always outside the patient's electronic chart.
The tool is a document with fields
The tool we use at Penn is a custom form built into the EMR, but not supported by the EMR vendor. It contains several free-text fields that are used to contain the following information:
- HPI – the patient’s story, which summarizes past hospital summaries combined with the story from the patient’s mouth
- Results – a list of recent imaging and laboratory studies, in summarized form. Imaging reports may be a page long, but we try to summarize the result in one or two sentences. This field grows as more studies are conducted.
- Problem List – a list of active problems (e.g. Hypoxia, Acute Kidney Injury, Sepsis, …), so we remember to address everything. Under each item, we list the differential diagnosis and what we are doing to solve each problem – this field evolves during the course of the hospitalization as each problem is diagnosed and addressed.
- Assessment and Plan – often redundant with problem list
- Home meds – a list of medications the patient was taking upon admission
- Cross Cover – a box containing the bare essentials: a one-liner (a one-sentence description of the patient), to-do list, and if-then
- To Do – contrary to the name, it does not contain the to-do list, but rather a log of past events. (It was designed to contain the to-do list but it does not print, so people opted to put the to do list on the cross-cover box instead) Past events are useful for patients who stay longer than several days, because new doctors take over and may not remember when things were done.
- Other Med Notes – this is where we write start and end dates for antibiotics, because near the end of a 14-day course of antibiotics, no one remembers when it started
- Misfit data – there are no fields for Past Medical History, Social History, and Family History, so we often hide those in one of the existing fields
Use cases
Admitting patients – When admitting a new patient to the service (usually through the emergency room or from clinic), providers populate the tool with relevant data. Most patients have complicated histories with prior biopsies and imaging that help inform management of the new problems. To populate the tool, providers reference data from several different systems (EPIC outpatient EMR, radiology database, laboratory database), requiring plenty of page-flipping and often takes about ten minutes. This task could be largely automated.
Generating progress notes – Daily progress notes are important for billing. Providers generate progress notes for each patient every day. The EMR has a feature to generate a progress note, which includes the most recent vital signs and laboratory values, and also takes a “snapshot” of data from the tool, like the Problem List field. The ability to “spin off” data into the progress note is essential; otherwise providers would have to document duplicate data.
Getting work done – While rounding, the team decides on the daily plans for patients. By the end of rounds, there may be thirty to-do boxes, and some are more time-sensitive than others. Because accomplishing these tasks requires moving around, providers usually print a document that contains only the “cross cover” fields, so they can carry the list in their pockets. Several times during the day, interns reconcile the electronic to-do list with their paper list. This could be streamlined if they could check off items from a mobile application.
Meeting the patients – On a provider’s first day on service, they usually print a “signout document”, which contains all fields for all patients. That way, they have quick access to all the data during rounds when they present to the team. The attending may ask, “when did the patient get started on vancomycin” for which the intern would refer to the “Other med notes” field.
Discharging – When providers discharge a patient, they produce a Discharge Summary that describes the entire hospitalization. This task requires copying pieces of information from the tool into a separate “discharge document” form within the EMR. Because the EMR does not allow opening two documents at once, users often copy fields to a Word Document and then back into the discharge document. This could be largely automated.
Handoffs – At the end of the day, providers hand off patients to the next shift. It’s not unusual for the nighttime doctor to hear about forty patients. If each patient took five minutes, handoffs would take more than three hours! Instead, providers will print a “cross cover” document from the EMR that contains the bare essentials, and the to do lists for the night, and the verbal description may be one sentence for each patient.
Covering – When a nurse calls about a patient with new shortness of breath, the patient will likely be unfamiliar to the provider. He or she will open the tool to quickly get an overview of the medical problems to better inform their immediate management decisions. Nighttime covering also involves waiting for test results to come back for which there are no alerts. Passive tasks therefore become active ones, because providers have to look for results every few hours. Automated alerts would simplify the job.
The essential features that make the tool useful
- Living document
– Providers need one document that gives all the relevant information.
Previously, providers would have had to piece together interval events
from many progress notes to get the story.
- Sharable/Accessible
anywhere – providers work in teams, and everyone needs access to the
same checklist in order to avoid redundant work. Further, patients are
scattered throughout the hospital, and we jump on and off computers
throughout the hospital, and we need access to the tool everywhere.
- Flexible (free text) – providers need to be able to copy and paste data to and from the tool
- Quickly accessible from EMR – the tool is often touched hundred times throughout the day, so quick access is essential.
Conclusion
These use cases have been greatly enhanced by the tool, and satisfaction is quite good at my hospital. That said, there is much room for automation and improvement. Providers have not been very good at describing their workflows, and historically homegrown solutions are replaced by "official" ones that are met with dissatisfaction. Designers have a unique opportunity here to design apps around the workflows, enhancing productivity and patient care.
