Reflections on Integrating Electronically Generated Sign-out Documents into the EMR

• 2/4/2010
• Author: Steven Berman
• Category: The Journal Blog
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A Case Where What Is Good for Doctors May Also Be Good for Patients

This week, Jonathan A. Bernstein, the lead author of “Improved Physician Work Flow after Integrating Sign-out Notes into the Electronic Medical Record,” which appears in the February 2010 issue, guests on the Journal blog. As the authors reported in the article, in Spring 2006 they developed an electronic, printable sign-out report within the electronic medical record (EMR) system at Lucile Packard Children’s Hospital. Dr. Bernstein takes this opportunity to reflect on some of the issues in developing and implementing this clinical care tool. We welcome your comments.

The team of physicians and software developers that had built this tool was very excited about what it could do. Practitioners would be able to remotely access and update sign-out documents that would be automatically updated with pertinent patient information from the EMR. Yet, we wondered if anyone would put the new tool to use.

To spur adoption, we announced the new tool’s arrival by e-mail to the housestaff, subspecialty fellows, and attending staff. Then we hit the pavement. Members of the development team met with the housestaff as a group and conducted a tutorial on the sign-out documents. During the following weeks, we went unit to unit, performing impromptu demonstrations. A co-author, Dr. Longhurst—an attending who was on service in late Spring—and his resident team were among the first to make regular use of the integrated sign-out tool. We also met with nurses, case managers, and social workers to let them know about the tool and to gather suggestions for how it might be helpful to them. Still, adoption in the first month was slow.

As shown in the article (Figure 2, page 75), use of the sign-out documents picked up dramatically in the second month after going live. Within several months, the new sign-out documents were in regular use throughout much of the hospital. However, in reviewing usage logs, we saw clearly that use was very infrequent in our neonatal intensive care unit (NICU). Discussions with providers in the NICU identified several barriers to adoption in this setting, which largely centered on  formatting of the printed version of the report. Because of the relatively high census, the sign-out reports were too cumbersome on paper. In Summer 2008, a NICU hospitalist, Dr. Jon Palma, took on the task of adopting the electronic sign-out tool for use on neonatal patients. He led the construction of a neonatal specific sign-out report, which went live in October 2008. This report used much of the underlying engineering of the initial sign-out tool but was modified to match the functionality and formatting of a stand-alone electronic sign-out tool that had been developed by neonatology fellow Dr. Ash Sangoram for use in the NICU. Dr. Palma is currently preparing a manuscript describing the adoption and impact of the NICU EMR integrated sign-out documents.

In addition to the positive impact on provider work flow, as we described in the article, the adoption of EMR integrated printable sign-out reports and the more recently developed neonatal sign-out report, have helped to build significant good will towards the EMR and computerized provider order entry at our institution. End users have seen the tools as examples of how the hospital’s IT department could be responsive to the day-to-day needs of care providers.

With the experience of nearly four years and tens of thousands of electronically generated sign-out reports behind us, we can report an exceptionally positive experience with their adoption. We have heard from colleagues at the University of Washington that recent efforts at EMR integration of their electronic sign-out system have also been very well received there. Tailoring hospital IT services to the needs of care providers can improve the work experience of care providers and be a source of good will towards EMR-centered patient care and safety initiatives.