The thoughts and opinions of a 35 year board certified emergency medicine physician blogging about everyday life, the role technology has played in the emergency department business, and the art of practicing medicine. The times have changed: Health-care IT, EHRs and Meaningful Use!
In a recent article by Mark Crane, the author makes the statement “The handoff of a patient from one physician to another has long been a weak link in the chain of care that can lead to patient injury and a malpractice suit. Vital information routinely falls through the cracks, and physicians are often confused about who is responsible for follow-up.”
This has been a problem for years and multiple attempts to avoid litigation have had varied results. At least half the focus and any Quality Improvement initiative was built around trying to find a systems solution to avoiding the endless misadventures.
In the old days of paper, blame for problems at this critical juncture of care was often laid on the nuance of paper itself. That is, a major criticism was about the handwriting and layout of the documents used, and it was heard often that one could not read or find things with needed ease and directness. The Electronic Health Record has changed the paradigm. Now it is easy to read, difficult to navigate, and may be less intelligible than scribble, when a computer processor has synthesized sentences. Meaningful information is hard to find on many electronic platforms. While the key information may be there (somewhere), what you are looking for is often unnecessarily difficult to access and/or act upon. But that is just the documentation piece; there is more danger in handoffs than simply documentation pitfalls.
The study by Crico Strategies found in malpractice cases that “about 30% of the cases include a breakdown in communication, according to its 2015 report.” Because malpractice suits lead to financial losses and psychological pain for those involved, it is worth thinking about how communications fail.
In most Emergency Departments, the entire staff turns over every 9-12 hours. Overlaid on this rotation of personnel are multiple turn-overs of patients that involve not only physicians (ED Physicians and Consultants), but also nursing staff, ancillary staff, support, and clerical staff as well. Our department created a turn-over sheet that asked key details and encouraged a real-time turnover by “rounding on and visiting each patient being handed over”. When patients spoke with their new and old provider together, it put an identifiable face of a caregiver into their minds, and forced elucidation of a timely plan for disposition. The patient and family would get a real-time progress report and that would hopefully help allay their anxieties and frustrations.
When both providers are not physically there, a whole layer of complexity is created with respect to the physician-patient relationships occurring in the ED. The phone is a poor way of turning over patients, but sometimes is necessary when a consultant is on the way and the ED doc is ending a shift. Notes in the Electronic Health Record may or may not be read. The article calls this " Is the concept of signal to noise," he said. "These systems generate a lot of noise, a high volume of data. But what happens when we lose the real signal, the important information we want to convey, amid all the noise?”
There are many pitfalls in the communication process. Sometimes the incoming doc does not really get the clinical picture and diagnostic plan envisioned by the first doc. Following up on abnormal tests is a common pitfall, that has leads to multiple QI programs. Sometimes they work; mostly they do not. When a patient has an abnormal test and does not get the information needed or does not understand the potential importance of real-time action, who or whom is at fault? Well, it is not a person who is a fault. It is the system. Solving the turnover dilemma requires system modifications, and all those providing care should buy in on it.
The problems are endless but a “Formal Turn-over Process” integrated with appropriate programming in the Electronic Medical Record can help. The trick is make the process essential for success but not overwhelmingly complicated and time consuming. “Clicks” cost time and money, as discussed in prior blogs. Anytime a turn-over event occurs, a good system initiates a safety process that can save the day (and save the patient) in the end. Such safety process should include discharging patients, turning over care to another provider, following up lab and x-ray tests, etc. The paper solution referred to earlier actually worked if used. But we are in a different era, and building in safety nets in key areas, such as with patient turnover, make the promise of an effective EHR closer.