Use of simulated physician handoffs to study cross-cover chart biopsy in the electronic medical record

Abstract

Clinical handoffs involve the rapid transfer of patient information from one provider or team to another, through activities which may introduce errors and affect care delivery. "Cross-coverage" requires quickly familiarizing oneself with unfamiliar patients whose management plans were established by another provider or team. Through this work, we describe physicians' information seeking approaches within an electronic medical record (EMR) during physician handoff and chart biopsy at a major academic medical center. We conducted simulated handoff sessions and interviews with 21 physicians using standardized patient cases and we analyzed screen capture data, and video and audio recordings of interactions with the EMR and handoff printouts. We found highly variable navigation of the EMR but greater similarity in physicians' EMR navigation behavior when the chart review was prompted by simulated interruptions. Understanding how physicians seek and assimilate patient data can inform handoff tool design and suggest strategies for explicitly supporting EMR chart biopsies.

Figure 1.

Sample sequence of differing navigation patterns for case A, with cued and un-cued EMR review. While there some similarity in common EMR sections, the sequence of navigation and time spent for a given case varies substantially between participants.

Figure 2.

Count of EMR sections that participants viewed as their first or second EMR page before and after receiving an interruptive cue (a text page). Structured information has been separated out into vitals (referred to as Other Results within the EMR system), labs, and medications in order to demonstrate the change in structured information after a physician received the cue event. While the number of times that physicians navigated to less structured information remained similar pre and post cue, we observed an increase in views of structured data sources.