Often, communication between providers for inpatient consultation remains dependent upon the use of hospital phone operators, pager devices, and web-based systems separate from the electronic health record (EHR). Given the growing complexity of multidisciplinary care, limited human resources, and time constraints, it is advantageous for hospitals to eliminate inefficiencies in communication wherever possible. We hypothesized that this need for streamlining clinical communication could be partly addressed by leveraging existing capabilities within the EHR (Epic Systems) to page consultants directly from the EHR. The aim of this study was to develop and pilot test this direct paging tool in the provision of inpatient care.
The pilot study was performed at a quaternary academic medical center from February 2017 to June 2017. An IRB waiver of consent was obtained. The direct paging tool was designed for consultations made to the pediatric pulmonology service. First, a virtual pager number was assigned to the pediatric pulmonology inpatient consult team in the existing web-based paging system (Spok). The on-call consultant was programmatically assigned to the virtual pager number. Next, a previously existing EHR order for pediatric pulmonology consult was modified to allow for the ordering user to enter their reason for consult and call-back information via phone and pager. This newly designed order was configured to send a page to the pediatric pulmonology virtual pager number upon the user’s signing of the order. In addition to the manually entered information provided by the end-user, the outgoing page automatically included the ordering user’s name, the patient’s surname, medical record number, age, and gender. Pre and post-implementation surveys were performed. The amount of time elapsed between order placement and the consultant’s accessing of the chart and note filing was compared using a Wilcoxon 2-sample test.
Fifty-six residents (60%) responded to the pre-implementation survey. Their responses indicated that 64% were either “very” or “somewhat dissatisfied” with the process for requesting inpatient consults, and 0% were “very satisfied.” Thirty-nine percent reported that it required 5 minutes or longer to request each consult order, and none reported being able to do so in less than 1 minute. 87% reported that the most time-intensive step was calling the hospital page operator to obtain the consultant’s contact information. Over the study period, 29 users placed 43 direct paging orders. Sixteen of these users completed a post-implementation survey. The proportion of respondents who were “very satisfied” with the new process increased to 81%. 75% reported the time required to complete the entire consult workflow was reduced to less than 1 minute, with the remaining 25% reporting less than 2 minutes. In addition, 69% indicated that the consult was placed earlier in the day (20 min – 1 hour earlier), allowing for earlier receipt of recommendations from the consultant (estimated range of 30 min - 1 hour earlier). When measured, the actual time for consultants to access the chart after a consult was ordered decreased from a median of 4.03 (IQR: 2.39-14.17) to 0.63 (IQR: 0.09-4.44) hours post-intervention (p=0.001). The time for consultants to file their note decreased from a median of 26.88 (IQR: 15.40-32.47) to 13.84 (IQR: 6.34-32.05) hours (p=0.159). Eighty-eight percent of respondents requested that similar orders be designed for all inpatient consultants, and that if these were implemented, 100% estimated they would save over 5 minutes per day, while 50% estimated they would save over 10 minutes per day. No instances of page transmission failures were reported. Consultants did report occasionally receiving non-urgent pages after hours due to use of these EHR orders.
Leveraging the ability to directly page inpatient consultants from the EHR holds significant potential for improving user satisfaction and efficiency, as well as expediting communication and subsequent receipt of consultant recommendations. The future of efficient multidisciplinary care coordination in complex health systems will depend on workflow optimization through similar integration of healthcare information and communication technologies. We are currently expanding our pilot study to determine the impact of this particular mode of paging consultations directly through the EHR on a wider scale in the health system.
Learning Objective 1: Optimization of inpatient communication workflow
Daniel Kozman (Presenter)
University of California, Los Angeles
Betty Tseng, University of California, Los Angeles
Kelly Lockett, University of California, Los Angeles
Myung Sim, University of California, Los Angeles
Mindy Ross, University of California, Los Angeles