Ivo van Schaik
We normally see the interaction between physician and patient as two parties relationship. I think a way forward is to envision a three party relationship: a triangle of communication. This should be taken quite literally in the lay-out of your office: create a triangle around a desk and not a patient face-to-face with physician with a computer in between. The computer with the EMR open is the third party and all other parties (patient and physician) can read and input on the system. At the university of Chicago they have introduced a acronym: HUMAN LEVEL: Honor ‘Golden Minute’; Use ‘Triangle of Trust’ ;Maximize Patient Interaction; Acquaint yourself w/chart; Nix screen;Let the patient look on; Eye contact; Value the Computer; Explain what you’re doing; Log Off. (ref’s: Lee & Alkureishi, MedEdPORTAL 2013; Mann, Permanente Journal 2004; 8(4);49-51.)
The basic message is that if the computer is introduced as trustable third party which can help in communication, making health care safer and more efficient and can be used as a source of information (storage and retrieval). In this way the computer/EMR do not have to stand in between patient and physician but is a helpful third partner
We implemented the SBAR and read back procedure as welling our hospital. However, it worked reasonably well in physician to physician handover, but still isn’t fully adopted by nurses and other caregivers. Nurse-physician handovers and nurse-nurse handovers are equally important for patient safety. One shortcoming is that our EMR (EPIC) is not supporting handovers in the way we would like them to occur. My feeling is that the digital environment have to support the handover methodology you want to use and in our case we have to adapt this within EPIC.
Nevertheless , I would also advise to implement SBAR methodology and would emphasize the importance not to forget nurses and other caregivers.
We face currently the same problem in our academic hospital and decided (among a lot of process improvements on the ER) we gonna create an ACU. This will be an 20 bed acute admission ward adjacent to the ER. The thought is that approximately half of the people which will be admitted to our ACU can be discharged within 24 hours. The other half will move out to one of the speciality wards in our hospital, are transferred to another hospital because the problem is not an academic one, ore are transferred to a local community nursing bed if they only need care and cure. We have arrangements with a few hospitals in the region for specific type of patients. Local community nursing beds is a new initiative: our geriatric specialist have taken up the challenge to build a small in-patient care facility together with GP which fills the gap between hospital and home-care. especially older people who suffer from a relative small medical problem not necessarily prompting admission but have to much care problems to be send home are excellent candidates for this new facilities. The ACU itself, alleviates the wards from handling admissions in the middle of the night, which makes it easier to have them staffed properly.
The problem is that physicians don’t trust the assumption of “less work/tasks for doctors”. The whole digital revolution so far has increased workload. Many physicians complain on using EMR systems. They have less time to interact with patients and treat them and are spending much time typing data into a computer or reporting in what ever way. Furthermore, reimbursement systems (at least in the Netherlands) do not pay for patient contacts via e-mail, patient-portals, apps or whatever new solution with which you could keep a patient out of hospital.
Last but not least and there I agree fully with Pelayo, in our hospital (and we are not an exception) we seems to lack an overarching mission and strategy how we want to communicatie with our patients and how we want to deliver how healthcare using modern digital options. I strongly believe that a shared vision will help people to embrace new technologies.
Apart from creating a strong culture in the hospital around these techniques, it is of importance to create an incubator for young HCP to play around with new ideas/innovations and provide some small funds to try out good ideas
Dashboards are only useful to end-users as they address the information needs of those users. Involvement of end users is crucial to get the metrics of the dashboard right. Many physicians are really interested in metrics as long as these ar trustworthy. We developed a few dashboards for clinicians and head of departments. We brought the clinicians together with financial and operating people together and discussed what metrics would be of interest and how these would connect to financial or operating metrics. This may widely vary between specialities.
Dashboard should also (depending on the metric) be timely. Some metrics ar important to follow more or less real time, others are well be collected every months or so. This frequency of refreshing numbers is also an important issue to discuss with the end-user. Finally, after having build an dashboard, clinicians should be asked for face-validity of the metrics; are the numbers in range of their expectations. If not their should be a collaborative effort to find out why the metrics are not up to expectations. Unless this step is taken, dashboard won’t be embraced.