Sunday, February 5, 2012

Could a new note, the Football, help improve healthcare?

As I've mentioned in previous posts, the American government cannot set up a national patient identifier. So projects like NHIN Direct generally rely on a document push mechanism which, essentially, allows one healthcare provider to push an authorized, HIPAA-secure document to another healthcare provider.

I'll admit it - I wish we could have pull.

The reason I want pull? A centralized, patient-centric medical record (like in the #SpeakFlower model) would make it much easier for various providers to pull and update information in a virtually central location. Pushing documents is going to have its workflow challenges, and leave some with the question, "Where is the patient's real chart?".

So since I recently became involved in our Massachusetts discussion on Health Information Exchange, I'm struggling with the question of how to implement a state-wide HIE system that will allow providers, at least initially, to push documents to eachother.

So my first informatics question, on being given this challenge, is : What will people push? Who will push it? And to whom? And when?

To try to answer these questions, I invited folks to our last Interstate 91 Informatics dinner in January to discuss "Can we do better than SOAP?" by asking everyone :

  1. What documentation do people want?
  2. Could we develop any group standard templates for standardized documentation, to save us all development costs?
  3. Could we develop any rudimentary, area-wide clinical governance so we can share documentation easier, and thus all benefit from a common language?
  4. Ultimately, who will push what documentation to whom, and when?

And after a rousing discussion, the answer I heard was this : Everyone has a different opinion.

I guess it's entirely understandable... ICU docs, PCPs, surgeons, specialists, hospitalists, and everyone else has a common goal - making the patient healthier - but they have different training and thus they all have different needs. This is why when I hear docs say "I just need the important information!", I smile because ultimately, all of the information in a chart is important - It just depends on your context and clinical needs.

So I'm left with the ultimate Informatics challenge - How can we get the right information to the right person in the right place in the right time in the right way? Especially when everyone has a different opinion on what the right information is?

And is there any way we can develop a standard lingua franca that all doctors speak?

Is there something that all docs would know how/when to use, in a standard way?


So to better understand the challenge here, I looked to the most common issues I hear doctors, nurses, and administrators talking about :

  1. Med Reconciliation (at virtually every stage of care)
  2. Handoffs inside a hospital
  3. PCPs wanting notification that their patient has been admitted
  4. PCPs wanting discharge summaries when their patients are discharged
  5. Quality
  6. Waiting times
And given the push mechanism it looks like we are going to get, at least initially, how are we going to set any standards?

There is one thing issues #1-6 above share : They are mostly all caused by the lack of a common, portable, #SpeakFlower-type, patient-centered chart, which we currently lack in modern private healthcare. (Note : I say private healthcare because the Veteran's Administration/VA VistA system actually has a pretty seamless, continuous, portable patient chart that only works inside the VA system for various political and cultural reasons...) 

But in a private, push world, is there any way we could we start to approach some kind of a portable, patient-centered chart?

In other words, is there any way we could leverage our push system in a way that actually simulates a patient-centered chart?

And how would we implement this?


Looking at the current buffet table of documentation, it's no wonder that every doctor has a differrent opinion of what they need. There aren't really any hard standards for clinical documentation. As I've mentioned in previous posts, most doctors learn about documentation from things like the Washington Manual Internship Survival Guide. So as a result, most physicians are familiar with things like :
  1. Admission H&P
  2. Progress Note
  3. Discharge Summary
  4. Transfer Note
  5. Encounter Note
  6. Procedure Note
  7. Visit Note
  8. Consult Note
And so when our Interstate 91 Informatics group got together, it's no wonder every doctor had a different opinion of which note they would want to get, and when.

So to look for inspiration on how to build a standardized document that every doctor would know how to use, and when to push to whom, again I thought : Could we make a standardized push document that approaches the portable, patient-centered chart we all want?

It dawned upon me that to solve this problem, we will need a new type of note. And so if it's something that's not in the Washington Manual Internship Survival Guide, it would have to be something that was so useful, so intuitive, and so desirable - like McDonalds French Fries - that every doctor would *want* to use this note, update it, and push it to the right person at the right time.

So then I thought - We are really asking for a portable, mini-chart that we can push around to the next provider.

And then I wondered, "What will we name it?" The "Mini-chart"? The "Patient Summary"?

What we're really talking about here is a "Patient Handoff Note" - The 'mini-chart' - And to make it extra-intuitive, I've decided to nickname it "The Football".

(Interestingly - "The Football" is also the nickname given to the "Nuclear Football" which the President of the United States carries around at all times, which according to Wikipedia is designed to be "a mobile hub in the strategic defense system of the United States" - A portable, role-centric tool for making important decisions... Huh! Talk about portable documentation!)

Also by nicknaming it "The Football", it gives users a visual clue about how to use it and when to punt it to the next physician.

The Patient Handoff Note ("Football") is basically a patient mini-chart, designed to be used in handing off care from one physician to another. In other words, physicians could think of the Patient Handoff Note ("Football") as a document that they update and push to the next physician expected to see the patient.

Who is the next physician expected to see the patient? Whoever is expected to see or cover the patient next. If you're a PCP expecting a specialist to see your patient, you'll update the football and send it to the specialist. If you're a specialist done with the consult, expecting the PCP to see the patient next, you'll update the football and send it back with the patient to the PCP

Of course, the key word here is expected - What if a patient has an unexpected trip to the ED?

I thought the note should be of such high value that, on arrival, the ED physicians would request the Football from the PCP. (By doing this, they would ensure the PCP knew about the visit.) And when the ED doc decides to admit the patient to the Hospitalist, they would update the football and push the patient and football to the expected Hospitalist.

And the admitting hospitalist could update and push the football to the expected hospitalist the next day. 

And the daytime hospitalist could update the football and push it to the expected overnight covering staff. 

And the overnight covering staff, if needed, could update the football and push it to the daytime hospitalist.

And the daytime hospitalist, on discharging the patient, could update the football and push the patient and football back to the PCP.

(To the patients reading this, I apologize - This is really referring to document management, not patients - I am definitely not endorsing pushing patients around!) :)

So anyway, back to the football - what could this Patient Handoff Note ("Football") look like?

Here's my first draft - As an example, I'll show how it could be used at the point of discharge :

DATE OF BIRTH   :   Jun 06 1966

Emergency Contact :
Tarkin, Emperor
Relationship : Father
Cell (914) 555-1212

Full Code (last verified by Luke Skywalker, MD, PCP, Internal Medicine, Oct 30 2009)

Feb 03 2012

Dirk Stanley, MD (Hospitalist, Internal Medicine)

(   ) Overnight Coverage 
(X) Other : Luke Skywalker, MD (PCP, Internal Medicine)

AUTHOR : (Note : This is who is pushing the football today)
1. Feb 03 2012 - Dirk Stanley, MD (Hospitalist, Internal Medicine)

CO-AUTHORS : (Note : this is essentially everyone who has pushed the football in the past, with last date they pushed it, in reverse date order)
2. Jan 28 2012 - Han Solo, MD              (Attending, Emergency Medicine)
3. Sep 22 2005 - Beru Whitesun, MD    (Attending, Gastroenterology)
4. Apr 02 2004 - Luke Skywalker, MD (PCP, Internal Medicine)
5. Apr 01 2002 - Ben Kenobi, MD        (PGY-1, Internal Medicine)
6. Feb 22 2002 - Owen Lars, MD         (Attending, General Surgery)
7. Jan 11 1996 - Leia Organa, MD        (Attending, Cardiology)

1. Mar 29 2002 - Bactrim (Rash/Hives)

PMHx/PSurgHx : (Note : This has all problems/history identified in reverse date order)
1. Feb 03 2012 - Aspiration Pneumonia
2. Feb 25 2002 - Cholecystitis, s/p cholecystectomy
3. Sep 22 2005 - Colonoscopy, s/p benign polyp removal
4. Jan 11 1996 - CAD s/p NSTEMI, no catheterization, medical management
5. Oct 12 1994 - Hyperlipidemia
6. Apr 03 1992 - HTN

SIGNIFICANT STUDIES : (Note : This is noted by docs, again in reverse date order)
1. Jan 28 2012 - 2-view Chest X-ray = (R)LL patchy infiltrate
2. Jan 04 2004 - PSA=0.06

Patient admitted to Mos Eisley Hospital on 1/28 with cough, fever, purulent sputum approx 3d after being found asleep and intoxicated at a party. Chest X-ray showed (R)LL infiltrate, WBC=21k, PMNs=80%. Started Zosyn IV and after 3d patient improved. Changed to oral Augmentin on 2/2/2012. Now ready for discharge today 2/3/2012.

1. Lisinopril 5mg PO daily
2. ASA 81mg PO daily
3. Metoprolol 25mg PO 2x/daily
4. Simvastatin 40mg PO daily
5. Augmentin 875mg PO 2x/day x7d, to complete on Feb 09 2012

1. Feb 15 2012 - PCP to follow-up with patient for routine follow-up visit
2. Mar 01 2012 - PCP to repeat Chest X-ray to ensure resolution of pneumonia
3. Apr 01 2012 - PCP to repeat lipid panel and LFTs to monitor Simvastatin dose
4. Apr      2015 - Gastroenterologist to repeat colonoscopy to follow-up benign polyps 
5. Jan       2020 - PCP to give repeat Tetanus vaccination 

SIGNED : __Dirk Stanley, MD_(Hospitalist, Internal Medicine)______ Date : Feb 03, 2012     
(My apologies to George Lucas - I'm obviously a big fan - Hope you don't mind me using characters to demonstrate this new medical note...!)

Anyway, I think the advantages of this drafted Patient Handoff Note ("Football") are this :
  1. It would be a very high-value note that docs would look and ask for (like McDonalds French Fries!) when receiving a patient :)
  2. After receiving the football from another physician, it makes creating your local documentation much easier.
  3. After receiving the football from another physician, it makes it very easy for you to update the football for the next provider.
  4. By making it something all doctors expected, it would drive ownership of the note by all physicians, so...
  5. ... It encourages docs to own, review, and continuously update the full med list, problem list, to-do list, allergy list, etc
  6. It makes med reconciliation easier for everyone.
  7. It could virtually replace notes involved in the expected transfer of care such as the transfer note, overnight coverage signout, discharge note, and consult referral
  8. Nicknaming it "The Football" makes it fairly intuitive about its importance and who to push it to and when
  9. In a push environment, in an unexpected transfer of care, an ED doc or Hospitalist requesting this from the PCP would pretty much ensure the PCP was notified about the admission in a timely basis.
It's definitely an off-of-the-beaten-path idea, but I'm going to suggest it to my fellow physicians here in Massachusetts, as we start to warm up our state-wide HIE and get it running. Will let you know the results!

Is this note wishful thinking, or just crazy? Always interested in feedback and questions! Send me your thoughts and ideas! Love the discussion just for education's sake!


emr and hipaa said...

I posted some questions in response to this post: I'd love to hear your thoughts on them.

AndreaKnowsEMR said...

Great post, great idea. I look forward to learning about the feedback from the docs in Mass.

Keith Boone said...

Dirk, this doesn't really work for me because you are trying to replace rather than enhance existing clinical practice. I like what you are trying to accomplish, but I think there's a better way to go about it.

Dirk Stanley, MD, MPH said...

Keith - I really like your recommendations. John Lynn also pointed out, "Why not just use CCD?" and I think you guys are right. But packaging it in a way that docs will want to use, and know how to use well, is the hard part that I'm more focused on. Unfortunately, in the absence of good clinical governance, it's really hard to develop clinical standards. Packaging, or "branding" the CCD in a way that was intuitive to docs could help drive adoption.
I'm still flattered I have the two of you commenting on my blog. I thought most of my readers were docs, not real technical gurus such as you and John.
Thanks for the input and comments!

Jack said...

I agree with Keith in that our greatest challenge and opportunity is to continue the evolution of both standards of content and the symantic interoperability of the data (content). Another important point (personal opinion) I'd like to make is about the current discussions around "what" to include or push. Dirk is correct that the "right" data to push is in the eyes of the reciver in the context of the current medical event (context). Its my opinion that we should push as comprehensive a summary document as possible and encourage the receiving applications to digest and present the data as appripriate to its user in the context in which it is being used. Simply stated, more is better.

Peter said...

Dr. Stanley - I really like the simple and concise "football" note that you developed. Having to recreate and consult with Ambulatory specialists on their note templates, it would be nice if they would just make them straightforward and real like the "football". However, in my experience as an Ambulatory Analyst, the information that is important for a Cardiologist is vastly different from that of a Sleep Medicine Physician. Also, many of the specialist that I work with have me create doc flowsheets that are then represented in tables within the note. I do not believe there could be a note to co-join everyone's interests without it not simply being the whole patient chart being pushed/pulled.