Published in the June 2005 issue of Today’s Hospitalist
Erik G. Van Eaton, MD, knew there had to be a better way. As a surgery resident at the University of Washington in Seattle, he was tired of copying patient information by hand from multiple electronic medical record (EMR) systems so he could create a summary sheet to use during rounds.
The solution? Dr. Van Eaton built a database that allowed him to collect critical information “patient names, room numbers, lab results, etc. “from those EMR systems. Once the information was in his database, he could print it out and create a rounding summary.
The idea was fairly simple: Residents and interns would have all the information they needed to round at their fingertips. They would no longer have to spend copious amounts of time copying lab values and test results into their rounding notes.
Dr. Van Eaton’s database worked so well that it caught the attention of hospital officials, who decided it might help the hospital comply with work hour rules liming housestaff to 80-hour workweeks. The result was UWCores, which loosely stands for the University of Washington computerized rounding and signout system.
Today, the more powerful version of Dr. Van Eaton’s database automatically collects clinical information from the other EMR systems being used in two hospitals where University of Washington residents work. Like the original database he designed, the UWCores system deposits patient information into a centralized source. Housestaff can then print out a summary to take on rounds.
But the UWCores system provides much more than basic information like patient names and room numbers. It lets housestaff exchange notes about diagnoses and problems with each other, along with instructions and plans.
Capturing informal communication
Dr. Van Eaton, who is now a surgery fellow at the University of Washington and an informatics fellow with the National Library of Medicine, says that the ability to provide nonstructured information is one of the system’s most powerful features.
And while giving housestaff the ability to exchange electronic to-do lists might not seem like a breakthrough, that information is often not readily available in many large EMR systems. That’s because many commercial systems, Dr. Van Eaton says, don’t have convenient places for the data that physicians would like to enter using their own clinical shorthand.
“One of the important things about a system like the UWCores system is that it augments the medical record to provide a method of communication,” he explains. “It’s not merely a place to record things that have been done. You get official information, but you also get the residents’ commentary about what needs to happen for the patient that day, what questions exist, and what the plan is.”
A study led by Dr. Van Eaton that was published in the April 2005 Journal of the American College of Surgery compared groups of surgery and internal medicine residents who did and didn’t use the system. Researchers found that the system cut in half the number of patients who were missed during resident rounds, allowed residents to spend more time with patients before rounds, and saved residents from 30 to 40 minutes a day. (For more information, see “Improved sign-outs and more time with patients: a look at the UWCores system,” sidebar.)
Because the UWCores system was built by a resident, it recognizes some of the subtle “and clinically important “ways that housestaff communicate.
“Physicians have very informal ways of communicating with each other that are very rich with clinical information,” Dr. Van Eaton says. “Their questions and observations that they haven’t verified oftentimes don’t go into the official medical record. Physicians instead communicate this information with each other, or they take note of it for themselves in a sort of clinical shorthand.”
A new paradigm
The UWCores system helps facilitate housestaff communication by serving as a bridge between larger EMR programs. “The enterprise-wide EMR systems do all the gathering of information,” he explains. “The UWCores system receives the information and formats it in a way that matches physician workflow.”
Dr. Van Eaton says the software uses an entirely different paradigm to address the needs of housestaff, who work on teams.
“When you log into an EMR system from one of the big vendors and call up information on a patient,” he says, “it asks about your relationship to that patient. The old paradigm is ‘One doctor, one patient.’ UWCores helps us get away from that old way of keeping patient information in silos.”
“UWCores recognizes that physicians oftentimes move in and out of team-based roles,” he says. “So when I want to access patient information, I don’t want it to remember me as an individual, I want it to remember that I just happened to be filling in for the intern on the service today. When I leave, I don’t want the information to keep flowing back to me, I want the information to flow to the next person who’s filling the role of intern on the service that day.”
Help for hospitalists
Since the research on the UWCores system was published, Dr. Van Eaton says he received a flurry of calls from academic medical centers that are under the gun to limit the work hours of their housestaff. He has also, however, been hearing from hospitalist programs.
“We’ve started getting calls from hospitalist groups who say, ‘We work at three different hospitals, none of which have the same medical record system,’ ” he explains. Even if one of the hospitals comes up with a solution to organize rounding and sign-outs, Dr. Van Eaton adds, the groups still need help collecting and managing information from the other two facilities. Because the UWCores system can consolidate information from disparate sources, it may be an ideal solution for those groups.
And while the UWCores system was designed with residents in mind, Dr. Van Eaton says it is a natural fit for hospitalists.
“Hospitalists don’t form a relationship first in a casual setting,” he notes. “They have to be able to walk into the hospital and have a system that says, ‘These are your patients, this is what’s wrong with them, and here they are.’ Whether that information comes from our software or 3 x 5 cards, the impact it has on efficiency may be even bigger than what our research has shown.”
Dr. Van Eaton acknowledges if individual hospitals want to implement his system, they will need to do some customization work. And while you can’t simply buy a copy and install it in a couple of hours, he views that as a good thing.
“You have to connect it to your sources of patient information,” Dr. Van Eaton explains. “By doing some of the ‘build’ locally, you have control over how the system presents data. While 90 percent of the information needs of clinicians is the same throughout the country, there is that little bit that everybody wants to do a little differently.”
In his mind, it’s one more important difference between the UWCores system and other commercially available products.
“That’s what the big vendors are discovering,” Dr. Van Eaton says. “You can’t give hospitals a shrink-wrapped set of DVDs. Everyone has unique needs in terms of how they want to manage patient information, and you have to do a lot of customization locally.”
Edward Doyle is Editor of Today’s Hospitalist.
Improved sign-outs and more time with patients
Can simple software that creates a patient census with basic information like patient name, room number and lab values improve patient care? According to researchers from the University of Washington, the answer is yes.
A study that examined the impact of the University of Washington’s computerized rounding and sign-out system, known as UWCores, found that interns and residents, at least, thought sign-outs went more smoothly and continuity of care improved.
That research, which appeared in the April 2005 Journal of the American College of Surgery, found that the system helped internal medicine and surgery housestaff in several ways:
“¢ Housestaff missed half as many patients during morning rounds. These problems often occurred when housestaff admitted patients overnight and forgot to notify the next housestaff team before rounds.
“¢ The system allowed residents and interns to spend 40 percent more of their time before rounds seeing patients. They also cut in half the pre-round time they spent copying by hand basic patient information to prepare for rounds.
“¢ Team rounds were shortened by about 1.5 minutes per patient.
“¢ Junior residents using the software said they saved an average of 45 minutes a day, while senior residents said they saved 30 minutes a day.