ProjectProposal-TomMcClure
From CS160 User Interfaces Fa06
Contents |
Patient Sign-Out Cards:
A Hospitalist Shift-Work Tool that can be Digitally Augmented
Healthcare professionals today still do a lot of writing by hand. Physicians -- hospitalists in particular -- continue to favor paper and pen solutions to many of their daily tasks despite the availability of tailored applications for workstations and PDAs. One application that is uniquely suited to the affordances of pen and paper arises in the domain of "Patient Sign-out Cards." These specially formatted 3x5 cards are the preferred method at many hospitals' medicine wards for the transfer of critical patient information from shift to shift.
Patients admitted to the wards need a high level of care and supervision. Doctors have developed a set of best practices for meeting the challenges of 24-hour care. The Sign-out Card is a key tool in this battle. In its current state the tool functions well, but with careful application of technology it could be improved upon.
THE PATIENT SIGN-OUT CARD: TODAY
Doctors on the wards work very long shifts, in part to ensure that the decisions made for their patient are made by staff that are most familiar with the patient's case. Inevitably, however, the doctor must hand over care for their patients to the next shift. Of course, doctors keep very disciplined records of everything known about the patient's case in their "chart." One might expect that the chart is the primary tool for transferring patient info from shift to shift, but in fact doctors on the wards supplement their chart use with the "Patient Sign-out Card" for this purpose.
The information on the card and the layout have become standard over time:
- CARD FRONT
- 1. Patient Identity (name, medical record number, room number)
- 2. The "One-Liner" ID -- age, gender and primary diagnosis / reason for admission to the hospital.
- 3. Code Status -- what to do if the patient "codes" ie heart/lungs fail
- DNR/DNI (do not resuscitate, do not intubate)
- Full Code (do everything possible to keep patient alive)
- 4. Problem List -- symptoms
- 5. Meds List -- drug/treatment and dosage (quantity/frequency)
CARD BACK
- 6. TO DO -- eg, check the results of a lab test that was ordered, etc.
- 7. IF --> THEN suggestions
- 8. (optional) Contact numbers for family.
The utility of this card system ensures its continued use even in hospitals that have made the transition to digital charting. Whether digital or paper, the chart is an inferior tool for moment-to-moment care. Paper charts must be kept physically close to the patient -- but physicians are often consulted about a patient when they are several floors away (and/or with no access to a desktop). Also, the chart is typically a tool for archiving a complete history of patient care, and up-to-the-minute summary information can be difficult to ascertain quickly.
A small stack of these 3x5 cards - one per patient - are easily kept in a whitecoat pocket, accessible wherever the doctor roams and easily handed off to the doctor taking the next shift. A single card often contains all the information that's necessary to care for the patient over the course of several shifts. As meds are discontinued or symptoms go away, they are crossed out with a single line -- an effective, concise history.
THE PROBLEMS
As with any paper-based system, there are drawbacks. The cards can get lost. Patients with extended stays eventually need their cards to be rewritten, especially if they display old lab results. The cards are usually destroyed and do not become part of the chart. It's hard to tell when certain items were added to the card and when certain strikeouts were made. Doctors are notorious for having poor handwriting.
In discussions with hospitalists there was interest in the ability to track and graph patient vitals and lab results -- which are recorded by hand on the cards using special notation -- over time.
PDA-based sign-out solutions have been suggested and tested, cf: Electronic Sign-Out Using a Personal Digital Assistant. However, PDAs can present a steep learning curve to some physicians, as well as privacy concerns. These solutions haven't always addressed the need to sketch compact lab results and record handwritten notes using medical shorthand (which often clashes badly with the widely used graffiti input system).
The Anoto digital writing system - in concert with a centrally served browser-accessible system - may be uniquely suited to providing a superior sign-out solution.
PROPOSAL
A new signout card system could be introduced with minimal disruption. By distributing digital pens and preprinted signout cards with the Anoto pattern, a system for capturing signout information and thus a digital archive of signout cards could be created.
A browser-based signout card retrieval system (keyed on the handwritten medical record number) would be fairly easy to layer on top of the archive, with pen strokes superimposed on the preprinted card. Most of the improvements to the work flow of the hospitalist would be in the use of this card browsing system.
For instance, if a card or set of cards were lost, they could be quickly located and reprinted. An animated history of the changes to the card could be created with a complete timeline and attribution of additions (based on pen ID). Handwritten lab results could be parsed so that changes in the patient's condition could be graphed over time.
ACKNOWLEDGEMENTS
Most of the information for this project proposal was gathered from my wife, Scarlet McClure M.D., who has worked in the wards at L.A. County and Santa Clara County hospitals and who recently wrapped up a year as Chief Resident at the Santa Clara Valley Medical Center.
