Useless Charts & Fresh Eyes in Handoffs

28 03 2011

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students.  They are not alone.  The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it.  I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs.  Would what I say be over their head and irrelevant if they had no clinical context?  I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case.  I had a lot of fresh eyes (and mostly ears) on the call.  In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information.  This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver.  In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way?  I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system.  Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one.  I said that the chart is a document that is an archive that is most helpful for those people that know the patient.  It is also one large medical bill.  And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision.  So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient.  The information there is overwhelming.  Our chief resident had a better answer.  The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information.   A handoff also has to include a verbal interactive component.  As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’   I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board).  Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs.  But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report.  However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!).   So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

So as we head into July 2011, here’s to more fresh eyes…

–Vineet Arora, MD

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5 responses

28 03 2011
Indian Health Journal

Communication is vital in Patient Safety. Shift Changes are critical periods during which communication between the incoming and outgoing personnel is of key importance!
Hand Off designed to hinder specific kind of risks are key to preventing issues, especially ones which have been learnt from.
You can also check out this presentation on Patient Safety at the Indian Health Journal

http://bit.ly/e7IJAU

30 03 2011
gcruze

There seems to be a base set of data elements needed from a Chart/EMR – dictated by the Receiver’s common ground understanding of the patient – to initiate dialogue between providers. At that point, it becomes an information volley of what “should be known” from the Sender’s perspective and what “wants to be known” from the Receiver’s. Most of this information is EMR based but needs Sender synthesis and interpretation. Other useful information like the social, emotional, and family dynamic of the patient – which may impact treatment plans – may not reside there.

Metaphorically speaking, you wouldn’t want to learn to speak english by starting with the A’s in the dictionary. It all about the words you need for today balanced with those you want.

4 04 2011
marciacatt

IMHO (in my humble opinion), it is the EMR which has made the medical chart essentially a useless document – in the handoff, and pretty much everywhere else. A single, mere stroke of a wand, and a paragraph of template trash is vomited into the document, and I would submit that 90% of what is recorded was truly not examined/evaluated. NL now means: “Not Looked.”
Bottom line: its gonna get worse, before it gets better.

8 04 2011
Daniele Mannina

Hello Vineet,
it’s Daniele Mannina from Viralbeat. Hope this mail finds you fine, I’d like to have a chat with you about something I believe you could be interested in.
If it is ok with you please contact me at this address: daniele.mannina@viralbeat.com.
Thanks.

30 09 2011
e-Handoff: Patient Signout System / Critical Care Communication, Patient Signout System, Handoffs, Useless Charts and Fresh Eyes in Handoffs

[...] One of the leading experts on the subject of resident signout and handoffs, Vineet Arora MD, discuss… Category : Handoffs [...]

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