A template-based computerized instruction entry system helps the comunication between doctors and nurses

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1 Digital Healthcare Empowering Europeans R. Cornet et al. (Eds.) 2015 European Federation for Medical Informatics (EFMI). This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License. doi: / A template-based computerized instruction entry system helps the comunication between doctors and nurses Toshihiro Takeda a,1, Naoki Mihara a, Rie Nakagawa b, Shiro Manabe a, Yoshie Shimai a, Kei Teramoto a, and Yasushi Matsumura a a Department of Medical Informatics, Osaka University Graduate School of Medicine b Division of Nursing, Osaka University Hospital 271 Abstract. In a hospital, doctors and nurses shares roles in treating admitted patients. Communication between them is necessary and communication errors become the problem in medical safety. In Japan, verbal instruction is prohibited and doctors write their instruction on paper instruction slips. However, because it is difficult to ascertain revision history and the active instructions on instruction slips, human errors can occur. We developed template-based computerized instruction entry system to reduce ward workloads and contribute to medical safety. Templates enable us to input the instructions easily and standardize the descriptions of instructions. By standardizing and combine the instruction into one template for one instruction item, the systems could prevent instructions overlap. We created sets of templates (e.g., admission set, preoperative set), so that doctors could enter their instructions easily. Instructions entered via any of the sets can be subdivided into separate items by the system before being submitted, and can also be changed on a per-item basis. The instructions were displayed as calendar form. Calendar form represents the instruction shift and current active instructions. We prepared 382 standardized instruction templates. In our system, 66% of instructions were entered via templates, and 34% were entered as free-text comments. Our system prevents communication errors between medical staff. Keywords. Communication, Medical Safety, Template Introduction In a hospital, doctors and nurses shares roles in treating admitted patients. Communication between doctors and nurses is necessary and communication errors become the problem in medical safety because of the possibility to harm the patients [1,2]. In Japan, to prevent communication errors, verbal instruction is prohibited and doctors write their instruction on paper instruction slips. Doctors instructions to nurses encompass medications and infusions, care of patients and their activities of daily living (ADLs). Here we refer to instructions related to patient care and ADLs as general instructions. Doctors instructions were usually written on paper in list form. When doctors revised their instructions, they terminated the previous instructions and wrote new instructions on lower column. There were many problems with paper instruction forms. 1 Corresponding Author.

2 272 T. Takeda et al. / A Template-Based Computerized Instruction Entry System First, the free-form structure of doctors instructions usually resulted in significant disorganization. Second, as new instructions were written in columns below the original instructions, the revision history and the active instructions were difficult to ascertain. Third, because doctors often forgot to terminate previous instructions when they wrote new ones, overlapping instructions occurred frequently. Electronic medical record (EMR) is expected to assist in hospital risk management, for instance by improving safety surrounding the entry of doctors instructions [3, 4]. We developed a computerized instruction entry system that helps the communication between doctors and nurses. To reduce communication errors, the system need to prevent instruction overlap and to clarify current active instructions. 1. Methods 1-1. Computerized instruction entry system If the system permits free-text instruction entry, the system could not solve the problem associated with paper instruction slip system, because the input method was laborious for doctors, instruction descriptions were not standardized, it was difficult to understand the revision history and active instructions. To solve these problems we generated a template-based computerized instruction entry system. Templates enable us to enter instructions easily and to standardize their descriptions [5,6]. The template we adopted in our hospital is called a smart template; it has a tree structure with the content master and entered patient data simultaneously expressed using XML. In a smart template, selection of items in the upper section expands the range of items that may be selectable in the lower section, and only entered items are converted into natural language The display method of the instructions There are two forms in which instructions may be displayed, list form and calendar form. List form enables us to display detailed instruction contents and makes it easy to notice the presence of new instructions. However, this approach makes it difficult to interpret instruction revision histories and currently active instructions, and it cannot solve the problems associated with paper instruction slips. The calendar form, on the other hand, displays instructions in a time series table, and enables us to easily discern instruction revision histories as well as currently active instructions. However, the calendar form has only a narrow area in which to display instruction details and is not helpful to notice the generation of new instruction. A computerized instruction entry system can solve these problems by displaying this information in another window or a tool tip, and by changing the colors of letters and backgrounds. We prepared calendar form window in our computerized instruction entry system. 2. Results 2-1. Application of template and management of instruction change To prevent instruction overlap by using templates, the systems must recognize the instruction change. Suppose that there were two instruction templates, "template A", "template B". If a doctor entered an instruction using "template A" and changed it

3 T. Takeda et al. / A Template-Based Computerized Instruction Entry System 273 using "template A" again, the system could easily recognize the instruction change. However, if a doctor entered the instruction using "template A" and changed it using "template B", the system could not determine whether this instruction is an instruction change (from A to B) or an instructions addition (A plus B). In order to resolve this problem, the template relating to one instruction had to be standardized and combined into one template, and all doctors must enter their instructions using this template. Standardizing a particular type of instruction prevent instruction overlap, because changing instructions will involve overwriting old instructions. We standardized items in the first section as compulsory input items which were viewed as content in the instruction system (Figs. 1-a). The unique instructions for each department or ward were located in the second section (Fig. 1-b). Because items that are not entered are not converted into natural language, these department- or wardspecific instructions do not interfere with the instructions given by another department. Fig 1. Example of the template for general instruction 2-2. Preparation of template set Doctors usually write their instructions at the time of patient events such as admission or before or after surgery. Before computerization, general instructions were written in boxes that were preprinted on instruction slips. These boxes indicated the instruction items necessary. With instruction entry systems, if doctors individually selected every template they intended to enter instructions into, a great deal of time was required and necessary instructions could be forgotten. For this reason, we created sets of templates (e.g., admission set, preoperative set, etc.) summarizing the items needed. Instructions entered via any of the sets can be subdivided into separate items by the system before being submitted, and can also be changed on a per-item basis Generation of instruction calendar We generated general instruction calendars in calendar form windows (Fig. 2). The instruction items defined by templates are located in longitudinal columns, and time series (7 days, including the previous day) are located in horizontal columns (Fig. 2-a). Instruction contents entered in the first section of a template are located in the cell at the intersection of the instruction item and the day of its execution (Fig. 2-b). Instruction details are displayed in tool tips (Fig. 2-c). When instructions are changed, the revised content is displayed in the cell at the intersection of the changed instruction item and date of its execution (Fig. 2-d). New instructions are displayed with a yellow background, so that nurses can notice the generation of new instructions (Fig. 2-e). The instructions of free text were displayed in the lower column (Fig 2-f).

4 274 T. Takeda et al. / A Template-Based Computerized Instruction Entry System Fig 2. The actual general instruction calendar 2-4. Number and types of instruction entries after system initiation We prepared 382 standardized instruction templates. Our templates consisted of 188 templates (49%) concerning with examination, treatment, and surgery, 78 templates (20%) concerning with patient evaluation and monitoring, and 32 templates (8%) concerning with patients ADLs. We created 89 template set masters. These template sets covered the following categories: instructions on admission (89 template sets, 25%), postsurgical instructions (16 template sets, 18%), and pre-surgical instructions (13 template sets, 15%). From January 2010 to December 2010, 203,225 instructions were entered into the system. Of these, 67,859 (33%) were entered using template sets, 65,729 (32%) were entered using a single template, and 69,637 (34%) were entered using free-text comments. Doctors in internal medicine tended to enter their instructions using template sets (43%). In contrast, those in surgical departments tended to enter their instructions using single templates (37%). Pediatricians tended to enter their instructions using free-text comments (43%). Although the instruction working group that standardized the instruction templates included a doctor and a nurse from the pediatric ward, the instruction templates were inadequate for instruction entry on the pediatric ward, and thus free-text comments were frequently used Number of incident reports before and after system initiation Finally, we analyzed incident reports in our hospital before (3,819 reports from April 2008 to March 2009) and after (3,575 reports from April 2010 to March 2011) system initiation. The number of incidents that were thought not to concern with EMR was 2,807 (73.5%) and 2,812 (78.7%), respectively. The number of incidents that were thought to cause by EMR was 13 (0.3%) and 25 (0.7%), respectively. The number of incidents considered to concern with doctor's instruction and nurse's operation was 818 (21.4%) and 686 (19.2%). 3. Discussion It is important that an EMR prevents communication errors between medical staff. In instruction entry system, the management of instruction changes and terminations is

5 T. Takeda et al. / A Template-Based Computerized Instruction Entry System 275 important. In the case of instruction changes, old instructions must be terminated to prevent overlap when a new instruction is entered. However, with our old system doctors often forgot to terminate old instructions and thus instruction overlap occurred. By using templates in the general instruction system, instruction descriptions are standardized. Standardizing an instruction item into one template helps clarify instruction revision histories and prevent instructions overlap because changing an instruction involves the overwriting of that it replaces. Our instruction entry system was designed for instructions to be entered via template, but doctors were permitted to use free-text comments to enter instructions for which suitable templates had not been prepared. However, free-text comments are unable to prevent instruction overlap. To make our system as robust as possible, instructions should be entered via templates as much as possible. In cases involving patient events such as admissions and surgeries, doctors entered routine instructions using template sets, while instructions not adequately covered by template sets were entered using single templates. Moreover, instructions that required significant flexibility not provided for by templates were entered using free-text comments. In cases of instruction changes, doctors did not use template sets, but used templates specific to each instruction item. Our incident reports analysis reveal that the number of incidents that were not concerned with EMR was almost same before and after system initiation and the number of incidents concerned with instruction was decreased after system initiation. Although, incident reports were voluntary reported, these data suggests that our template-based instruction system helps the communication between doctors and nurses and prevents communication error. Conclusion We developed a computerized instruction entry system. The system displays the instructions in calendar form window that helps nurses to notice instruction shift and current active instructions and prevents communication errors between medical staff. References [1] Bassi J, Lau F, Bardal S. Use of information technology in medication reconciliation: a scoping review. The Annals of pharmacotherapy 44(2010), [2] Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 348(2003;), [3] Uto Y, Kumamoto I, Muranaga F, Usuku K. Risk Management and Hospital Information System.- Development of Risk Management System for the Quality of Nursing- Japan Journal of Medical Informatics 21(2001), [4] Pelayo S1, Anceaux F, Rogalski J, Elkin P, Beuscart-Zephir MC. A comparison of the impact of CPOE implementation and organizational determinants on doctor-nurse communications and cooperation. Int J Med Inform. 82(2013), [5] Yamazaki S, Satomura Y, Suzuki T, Arai K,Honda M, Takabayashi K. The concept of "template" assisted electronic medical record. Medinfo. 8(1995), [6] Matsumura Y, Kuwata S, Yamamoto Y, Izumi K, Okada Y, Hazumi M, Yoshimoto S, Mineno T, Nagahama M, Fujii A, Takeda H. Template-based data entry for general description in medical records and data transfer to data warehouse for analysis. Stud Health Technol Inform. 129(2009),