Workflow Improvement and Increased MD Satisfaction After Integration of Sign-out into the EMR Jon Bernstein MD, PhD 1,2 Dan Imler, MD 1,2 Christopher Longhurst MD, MS 1,2 1 Department of Pediatrics, Stanford University School of Medicine 2 Lucile 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.

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.”

Outline Integration of sign-out documents into the EMR –Background –Solution –Outcomes –Future work

Lucile Packard Children’s Hospital 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

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

“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.” NEJM, June 2003

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.”

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

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

Signout Form

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

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

Usage of Signout Form

Resident Reported Patterns of Usage p<.001 Day to Night, p<0.05 Night to Day X 2

Satisfaction with Primary Sign-out Tool p<.01, X 2

Resident Perception of Decrease in Redundant Data Entry p<.01, X 2

Resident Perceptions of Patterns of Communication

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