People have said it before, and will continue to say it, but there’s got to be some better way to collect and review data for medical and surgical teams. Let’s brainstorm and figure this out, people; the current system just ain’t so hot. And if grocery stores and airlines can get themselves electronic and digital, we in the medical world should be able to, too.
I’ll first describe how we collect data nowadays, and then suggest some improvements. I welcome yours in the comments.
“Rounding” is where medical teams review a patient’s course and data over the last 24 hours and decide what to do or not to do. In order to do this, someone has to go around and actually collect the data, see the patient, etc. This is called “pre-rounding.” Currently a medical student, intern, or resident walks around to all their patients, with a sheet of paper in his or her white coat pocket for each patient. You either go to the computer or the chart, and copy down the patient’s vital signs (BP, Pulse/Heart Rate, Temperature, Respiratory Rate, and Oxygen Saturation), labs, and study results from the master copy in the chart or computer onto your dinky little piece of paper. Then you go see the patient, ask how he or she is feeling, if there were any problems or complaints, and examine the patient. (This is usually very early in the morning; you have to wake up the patient.)
You then write a note on the patient, which is a “master copy” that goes in the patient’s chart of everything you’ve just written onto your own sheet, but in a more standardized format and also includes what you’re going to do for the patient based on his or her problems. (Sometimes people just photocopy their note and use that as their pocket reference, but then you end up with a ton of papers per patient.)
Your own little piece of 8 1/2 by 11-inch paper is your lifeblood. It usually lists all of the patient’s medical problems, the medications they’re taking, their intial labs, their story of why they came into the hospital, etc. It also lists all the labs they’ve had while they’ve been in the hospital (sometimes this spills onto a 2nd page if they’ve been in the hospital awhile). If you lose this, you are screwed.
Why do we need this sheet? Because the note we write has to stay in the chart–either electronically or physically. But we also need to have quick access to all the patient’s data throughout the day, in case someone needs to double-check something, or the patient gets very sick during the day, you can recall what happened before he or she got sicker.
Then when you actually round, you sit down with your team (or walk around to each patient’s room) and discuss each patient. You repeat aloud everything you’ve already written down twice (once for your own sheet, once for the official chart note), and discuss what you think should be done for the patient.
It’s an incredibly inefficent system, especially when you consider how busy doctors are and how much time is spent doing it. It hasn’t changed in years–have we been rounding like this since 1900?–and maybe it’s time for a medical culture shock?
- We need to have immediate, constant access to patient data.
- We also need to have a centralized source of patient data and care plans so that everyone caring for the patient can access it and see it.
- We need to be able to have access to all data, but be able to filter it or customize it based on what is important to us (a surgeon cares about different data than an infectious disease doctor).
- We have to go see each patient every day to re-assess them, see if there were any problems that we didn’t hear about over the last day.
- What if we just wrote a note once, but we could access it remotely? So you would write your full note, in official form, but then on a Palm-pilot device (or even more simply, a Nintendo DS or PSP), your note is also saved onto your own device as well, just in short form. I know, I know, everyone has their own system for how they track patients and labs, but perhaps it’s at the cost of efficiency?
- What if we just rounded with a laptop or other wireless device that was hooked into all the other systems? So just one device per team, and you could automagically tap into all the data available at the hospital?
- Both systems would allow templates and customization to some degree, so you could say, exclude certain types of data or organize it more efficiently.
- What if outside every patient room, a one page, formatted, color-coded summary was shown (password-protected or something). So you could walk up to the room, see if there were any events or complaints, quickly skim lab values and x-rays to see if there was anything relevant you needed to ask the patient about? You would know that all the lab values were already pulled and ready for you, so you wouldn’t have to write them down twice.
- Or perhaps the concept of a “note” is the entirely wrong format now that we have technology. (I’m just waiting to hear the cries and screams from the old-school.) Maybe it makes more sense to have a centralized patient “databoard” or “notebook” or “daily summary” that everyone accesses. It would list any new labs (with trends) over the last day, links to Xrays or reports, new complaints, new procedures done and the results, etc. And then from that patient databoard, you build a streamlined note that references the data. Drag and drop. Want to comment on a patient’s rising potassium? The note makes a link to that lab value, and you say what you want to do about it. Instead of seeing what a particular doctor or service would like to do, you could look at the data based on each problem (a high potassium, a consolidation in a chest film) and see what people are suggesting to do based on that problem.
Some of these suggestions are probably just because I’m on a consult service this month and don’t have my own patients, but I’d love to hear your thoughts on other problems with rounding and any ideas for solutions.