SummaryCommunity-based physicians referring patients to Northwestern Memorial Hospital for emergency care send an electronic handoff note to emergency department personnel to notify them that a patient will be arriving and to provide clinical details pertinent to his or her condition. The note, which includes the patient's name, date of birth, the referring physician's name, a clinical summary, and other information, is entered into the system's electronic medical record, where emergency department clinicians can easily access and review it at the point of care. Anecdotal feedback from physicians suggests that the program has improved physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.Suggestive: The evidence consists of anecdotal feedback from referring and emergency department (ED) physicians on the program's impact on physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.
Developing OrganizationsLyle Berkowitz, MD; Northwestern Memorial Hospital; Szollosi Healthcare Innovation Program
Date First Implemented2008
Problem AddressedPhysicians who refer patients to the ED have valuable information to share regarding the patient’s health history and status. The referring physician typically calls the ED to communicate this information to triage personnel who make brief handwritten notes (often called “expect notes”).1 However, these notes often cannot be located when the patient arrives or may be confusing or incomplete, delaying care and possibly prompting a followup call to the referring physician.
- Typical referral based on telephone call: As in most communities, physicians sending patients to the ED at Northwestern Memorial Hospital would telephone the ED to notify staff that a patient would be arriving. The referring physician would provide pertinent information to the triage nurse, who would create an informal handwritten note to share with the ED physician providing care.2
- Leading to incomplete or lost information: Because hospital EDs tend to be chaotic environments where triage nurses and other staff are typically very busy, notes often are incomplete, lost, or even attached to the wrong patient chart. Recovering the note or telephoning the referring physician creates inefficiency and care delays that can be detrimental to patient outcomes.2
Description of the Innovative ActivityCommunity-based physicians electronically notify Northwestern Memorial Hospital’s ED that a patient has been referred for emergency care by creating an electronic handoff note. The note, which includes relevant demographic information, expected arrival time, and a clinical summary, is entered into the system's electronic medical record (EMR), so that hospital clinicians can easily access this information at the point of care. Key program elements include the following:
- Physician-created handoff note: The referring physician logs into the practice's EMR to create the note with a template-based tool called "ExpectED." The template includes the following data fields:
- Mandatory demographic and clinical information: Mandatory information includes the patient’s name and date of birth, the physician’s name, and a general (free-text) clinical summary. A notation above the clinical summary free-text box asks clinicians to consider communicating pertinent clinical information based on “situation, background, assessment, and recommendation” (SBAR).
- Optional information: The physician can also provide optional information, including their contact information, when they would like to be contacted, how they evaluated the patient (e.g., by telephone, in person), whether additional patient data are available (and if so, where—such as elsewhere in the EMR or in a different electronic system used by another physician group on campus), the patient’s method of transport and expected arrival time, a list of preferred specialists, and the patient's expected disposition (e.g., discharge home, hospital admission).
- Telephone option for physicians who prefer that approach: Some physicians still prefer to telephone the ED with a patient referral. In these cases, a unit secretary (rather than the triage nurse) opens the ExpectED template, prompts the physician to provide the information, and completes the handoff note on the physician’s behalf.
- Information available at point of care: When the ED physician examines the patient, he/she opens the handoff note in the EMR, giving him or her ready access to complete and accurate information about the patient at the point of care (when such information is most relevant).
Context of the InnovationNorthwestern Memorial Hospital is a 900-bed academic medical center in Chicago with 56 ED beds. Five attending physicians and up to 28 nurses treat as many as 300 ED patients in a 24-hour period. In the interest of improving efficiency and quality in this busy setting, ED and hospital leaders agreed to participate in a pilot of the ExpectED tool, developed by the Szollosi Healthcare Innovation Program, a nonprofit health care technology development firm that focuses on information technologies to facilitate provider communication and care coordination. Dr. Lyle Berkowitz, an internist who founded the program in 2008, practices at Northwestern Memorial Physicians Group. As the largest primary care group in the Chicago area, its physicians refer a high volume of patients to the Northwestern Memorial Hospital ED. Dr. Berkowitz and his colleagues had become frustrated that the expect notes created in the ED often were lost or misplaced and decided to make solving this problem one of the Szollosi Healthcare Innovation Program’s first projects.
ResultsAnecdotal feedback from clinicians suggest that the program has improved physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.
Suggestive: The evidence consists of anecdotal feedback from referring and emergency department (ED) physicians on the program's impact on physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.
- Growing use of handoff note: The use of the handoff note has doubled over time, a fact that program developers say indicates its success and value. Several months after program inception, approximately 7.5 percent of patients seen in the ED had an Expect ED note in their chart. As of February 2011, this percentage has increased to 15 percent; about half are completed by the referring physicians filling out the EMR form, and the other half are completed by the unit secretaries taking incoming calls from referring physicians.
- Greater physician efficiency: Referring physicians who use the program report that referrals to the ED are now much easier and more efficient. They cite greater care efficiency due to the fact that they can quickly input and send relevant patient information at a time convenient for them, rather than having to telephone the ED and wait for a triage nurse to take the call (often a frustrating process). They also report greater satisfaction since they no longer receive telephone calls (sometimes hours later) from an ED physician who never received (or got incomplete) information about the patient.
- Better care coordination: ED physicians often refer to the handoff note in their own EMR notes, specifically by explaining clinical findings and actions taken directly in response to its content. Referring physicians believe that this approach improves the coordination of care between themselves and the ED physicians.
- More timely, higher quality care: Both referring and ED physicians believe the program has improved the quality and timeliness of care, because ED physicians now have access to complete information about the patient. In addition, care delays no longer occur due to the need to track down a referring physician for information when a handwritten note has been lost.
Planning and Development ProcessSelected steps included the following:
- Identifying ED champion: Dr. Berkowitz contacted a colleague, Dr. Martin Lucenti, an ED physician and medical director of ED operations at Northwestern Memorial Hospital. Readily recognizing the issue, Dr. Lucenti agreed to provide input into program content and ED workflow issues, and more generally to support the ED’s use of the program. (As a clinical quality improvement project, the project did not require formal approval from hospital leadership.)
- Determining clinician interest: Using a simple online tool called Survey Monkey, Dr. Berkowitz surveyed physicians in his medical group to obtain feedback on the quality of their current communications with the ED and determine whether they would be interested in using a Web-based program to convey pertinent patient information to ED clinicians. Dr. Lucenti and Dr. Berkowitz met with ED nurses to determine their interest in receiving printed information from referring physicians.
- Developing Web-based system: Dr. Berkowitz purchased programmer time from the Northwestern Memorial Faculty Foundation’s information technology (IT) department to design a simple and secure Web-based page with the handoff note template. Because the ExpectED program was initially designed before the ED used an EMR, the first iteration involved transmission of the Web-based handoff note to a dedicated printer located at the ED triage desk.
- Pilot testing: The ED pilot tested the program in April 2008 with physicians in Dr. Berkowitz’s practice. Physicians became aware of ExpectED via intranet notices, presentations at monthly meetings, and distribution of two sets of “frequently asked questions” (one for referring and one for ED physicians).
- Making incremental changes: Physicians provided informal feedback and reported any technical difficulties they experienced during the pilot to Dr. Berkowitz. Programmers made incremental changes in response to this feedback over an 8-month period.
- Integrating handoff note into EMR: After the ED started using an EMR in 2009, programmers integrated the ExpectED template into the EMR, eliminating the need for the Web-based program and the printed notes. (Note: When program developers made the conversion from the Web-based system to the EMR system, they identified a new physician champion—Dr. Michael Schmidt, the ED's medical director of operations—because Dr. Lucenti was serving in the Middle East.)
- Shifting handoff note completion to the ED unit secretary role: Feedback from ED staff revealed that the triage nurses felt their work was interrupted when they were asked to document phone calls from referring physicians. As a result of this finding and of having a more consistent handoff note format and location, the task of documenting the incoming calls was shifted to the ED unit secretary, who uses the template to capture the relevant information and create the electronic note on the referring physician’s behalf.
- Current expansion: Program leaders are working to ensure that all ED staff know about and use the ExpectED feature in the EMR and to stimulate interest among other referring physicians in using the system.
Resources Used and Skills Needed
- Staffing: Upfront development required programming staff time and time spent by physicians in planning and developing the system. Ongoing operation of the system requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: Development costs totaled $7,500 in software programming and project management fees. Additionally, physicians and ED staff involved in the project donated their time. Referring physicians and ED staff use the program at no cost.
Funding SourcesSzollosi Healthcare Innovation Program
The Szollosi Healthcare Innovation Program, housed within Northwestern Memorial Hospital's nonprofit foundation, funded the program's development. Szollosi receives its funding through philanthropic donations.
Tools and Other ResourcesPotential adopters interested in reviewing the ExpectED computer code may contact the innovator.
Getting Started with This Innovation
- Leverage a "pain point": By identifying a significant "pain point" for referring physicians (i.e., physicians were frustrated with the time and hassle it took to access the ED triage nurse, and with the low probability that their message would be seen by the ED physician), program developers knew there would be interest in creating a system to compete with the status quo.
- Identify ED clinician "champion": This champion can ensure that the handoff note remains top-of-mind among ED clinical staff.
- Separate mandatory and optional information: Designating some fields as optional may make use of the note more palatable to busy physicians.
- Determine how note fits best into ED workflow: The program should be designed not to disrupt (and ideally improve) ED workflow. For example, after Northwestern Memorial ED clinicians realized that triage nurses did not need to be involved in collecting and reviewing the handoff note, they redesigned workflow related to the note to the unit secretary, which meant fewer interruptions for the nurses.
- Pursue “independent” IT projects: Pursuing simple IT technology projects as stand-alone initiatives (i.e., separate from new or existing EMR infrastructure, to be integrated into it later) allows for innovation, creativity, and the ability to test new ideas quickly.
Sustaining This Innovation
- Continually highlight note's value to ED physicians: Some ED physicians may choose not to look at the handoff note while caring for patients. To overcome this tendency, periodically remind them that the note contains valuable patient information. In addition, provide ongoing education about the program, particularly in academic medical centers where medical students and residents constantly rotate in and out of the ED.
- Train new physicians and staff on program: Information regarding use of the handoff note should be incorporated into the training of new ED physicians and staff, including residents and students.
- Increase usage: Consider how to make the system more palatable to physicians. By having the unit secretaries use this system for all incoming calls from referring physicians, the number of handoff notes available in the EMR doubled to 15 percent. Over time, as the handoff note is recognized as being routinely available, the ED physicians will automatically incorporate it into their workflow. Additional education to referring physicians about this system is expected to increase this number further.
Additional ConsiderationsWith the use of the first (Web-based) iteration of ExpectED, the referring physicians would complete a Web-based form, which would automatically print in the ED and be inserted into the patient's paper chart. In late 2009, when the ED moved to the EMR system, it made sense to evolve the handoff system. Now, an EMR-based form posts into the ED flowsheet electronically. The upside is that referring physicians no longer have to sign on to a separate Web site to complete the form, and the ED doctors no longer have to look for the paper handoff note. The downside is that only providers who can access the EMR can create a note. Technically, all of the hospital's doctors (more than 1,500) can use the hospital's EMR, but only about 20 percent regularly use this EMR in their ambulatory workflow; other doctors use either another EMR system or a paper-based system.
Contact the InnovatorLyle Berkowitz, MD
Northwestern Memorial Physicians Group
1913 W. North Avenue
Chicago, Illinois 60622
Innovator DisclosuresDr. Berkowitz has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesExpectED: Light App That Automates Patient Hand-off To ER. HealthSpottr. September 10, 2009. Available at: http://healthspottr.com/weeklydigest/16-expected-light-app-that-automates-patient-hand-off-to-er.
Szollosi Healthcare Innovation Program (SHIP). The Expect ED Project. Available at: http://www.theshiphome.org/ExpectEd.html.
2 ExpectED: Light App That Automates Patient Hand-off To ER. HealthSpottr. September 10, 2009. Available at: http://healthspottr.com/weeklydigest/16-expected-light-app-that-automates-patient-hand-off-to-er.
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Original publication: July 20, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 13, 2013.
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