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September, 2009

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http://healthspottr.com/weeklydigest/16-expected-light-app-that-automates-patient-hand-off-to-er
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ExpectED: Light App That Automates Patient Hand-off To ER

What:  A web based software application that allows physicians to electronically notify an emergency room of an incoming patient, and advance case-critical patient stats--the "expect report"--to the urgent care team.

When: Initial pilot launched, April 2008. Phase II, which will integrate ExpectED with EMRs, is currently underway.

Where: Northwestern Memorial Hospital, an affiliate of the Feinberg School of Medicine at Northwestern University, in Chicago, IL.

Who: Created by Dr. Lyle Berkowitz, a practicing internist with Northwestern Memorial Physicians Group (NMPG) in Chicago, IL. He is also a future health 100 member.

Why: Replaces the time consuming and error prone tradition for "handing off" a patient to the ER: a doctor-to-doctor phone call and lots of manual notetaking. Web based ExpectED reports are easy for referring docs to produce. Sent electronically, they are also a efficient way to deliver critical patient data to a trauma team without interrupting ER workflow. Asynchronous communication between doctors improves quality; the patient report is produced when the information is fresh to the referring doctor, not an hour later in a call with the ER doc. The report is also accessed only when the ER doc is ready to focus on it; no interruptions, less confusion. This equates to more efficient and higher quality care. ExpectED's next pilot will experiment with integrating ExpectED reports directly with Northwestern Memorial's EMR platform (Cerner-based). Phase I ExpectED software is open source and available for free by contacting Dr. Berkowitz. Any doctor can try it -- we encourage you to do so.

Cost: free

When the internist known as "Dr. Lyle" isn't seeing patients at his Chicago-based primary care practice, he is directing the Szollosi Healthcare Innovation Program, a nonprofit incubator he co-founded in 2007 to develop healthcare technologies and IT tools for clinical use. An Associate Professor of Medicine at the Feinberg School of Medicine at Northwestern University, Dr. Lyle is also an expert in health informatics and has authored numerous articles on the topic. He likes technology, a lot.

ExpectED is the first project to come out of the Szollosi program (SHIP). Berkowitz came up with the idea for replacing doctors’ handwritten "expect notes" based on his experiences sending patients the emergency room at Northwestern Memorial Hospital. Dr. Berkowitz’s primary care practice is the largest in the Chicago area and he is known to his peers in the Northwestern ER as a “large volume referrer.”

Berkowitz had grown frustrated with the old method: he'd make a phone call to a triage doctor or nurse who would then take down notes on the expected patient. (Hence, the term “expect note.”) But by the time Berkowitz’s patient arrived at the ER, often hours later, these handwritten notes were sometimes misplaced or even attached to the wrong chart.

"ER's are chaotic places and little slips of paper are bound to get lost,” Dr. Berkowitz says. Time diverted or wasted trying to recover information on a patient by hunting a paper trail or by calling a referring doctor again, comes at cost.

“When I have to stop treating one patient to take an expect note on another the quality of information is degraded,” says Dr. Martin Lucenti, Vice Chair of Clinical Operations at Northwestern, and Dr. Berkowitz’s collaborator on ExpectED. “Ours is a system where delaying person only delays the next. So anything you can do to help the patient in front of you, to make it more efficient, allows you to [work] better and faster -- with better outcomes."

In April 2008, the pair launched a beta test of ExpectED, limited to physicians in Dr. Berkowitz’s practice and urgent care staff in Dr. Lucenti’s ER. Version 1.0 is a simple, web based application. A referring doctor logs into ExpectED’s secure site and creates a new note with the patient’s DOB, location of the recent evaluation and expected arrival time at the ER. The substantive data is in the SBAR section (“situation, background, assessment and recommendation”), where existing conditions, meds and the referring doctor’s opinion is recorded. Referring docs also include their “preferred consultants,” specialists’ names should any become necessary.

ExpextED faxes them to an urgent care desk where they are printed and filed by a nurse. (Screenshot at right, below.) It’s not ideal, as it still uses paper. But there are no more time-hording phone calls or error-prone scribbles.

"It was a big process improvement, because it took the doctor out of the information exchange system," says Michael Schmidt, the current Medical Director of the Emergency Unit at Northwestern Memorial. Keeping doctors at the bedside matters in an ER like Northwestern’s, where, at peak volume, five attending physicians and 22 nurses will treat between 240 and 290 patients in a 24-hour period. Imagine the amount of data flowing through Dr. Schmidt’s ER at peak traffic. Getting the correct and prioritized information on a patient to the doctor at the moment when it is most valuable—as the patient is being examined, rather than hours before—is the difference between good care and sub-par care.

This kind of information allocation requires high quality but asynchronous communication, which isn’t easy to achieve in a low-stress environment. (Think of the game telephone.) ExpectED makes high quality asynchronous communication between doctors just a bit easier.