Rounding with the housestaffIn October, I rounded on the inpatient hematology service for two weeks as the inpatient attending. I was with a heme onc fellow and a clinical pharmacist, and two teams each with a Resident, two Interns, and a medical student. The attending is the teacher as well as the physician of record for each of the patients, and responsible for writing, reviewing and signing notes, as well as overseeing the care of these patients with malignant hematologic illness. The 835 bed University Hospital went live with the Eclipsys Sunrise Clinical Manager product as a CPOE system in April, 2008.
As part of the implementation each patient room has a computer terminal fixed to the wall, generally on the wall at the foot of the patient's bed. There are also COWs (computer on wheels) available. The wall mount computers have the advantage of large bandwidth, so we can view radiologic images on them, but they are placed so that we have to turn our back to the patient when we use them. On the other hand, the wireless COWS are light and mobile, and many teams have taken to pushing them around with them. Currently the battery life is such that they don't last four hours -- but neither should patient care rounds -- and someone has to remember to plug them in to recharge their batteries.
Another advantage of the COW is that it can be positioned so that the screen is visible to the pateint. Doing so reminds us that we're not dealing with an iPatient, Verghese' term for a patient who has ceased to be a living, breathing, sufferring and responding person and is instead one among many icons with which the housestaff deal. We try and use the computer to demonstrate, as one of the Residents is doing in the photo at left, the patient's serial laboratory results, an item on which our patients -- most of whom are neutropenic and awaiting recovery of their neutrophil and platelet counts -- are fixated upon. We also, when we can, show images of their CT scans, their path reports and other relevant data (We order a lot of imaging).
I try to incorporate the computer and its information into my teaching and into my patient care. One of the learning goals I lay out at the beginning of our sessions is that the residents will be as comfortable integrating the computer information into their patient interactions as they are with discussing lab values, radiologic images, paper records, and information from their own physical examination. At the outset of the rotation, I make it an expectation that the intern or resident who is not presenting the patient's history to the rest of the team, will fire-up the computer, so that we can then integrate this information into the discussion we all have with the patient.
Another advantage of having the computer at the point of care is quickly entering orders. If we decide that the KCl needs to be adjusted in the iv or the vancomycin needs to be stopped, we can do it immediately. This alleviates the need for Intern and Resident to each scribble a note to themselves, and later enter the order, then have each one check to make sure that it was done, and it may reduce the information in the hand-off to the next team. A small thing perhaps, but in the era of limited duty hours, each piece of scut removed adds to the time available for teaching and patient care.
This hasn't been easy, and takes constant reminders. Some of the annonymous feedback I receive as part of my faculty evaluation by the housestaff has been brutally critical of this technique. I have to re-inforce the sign-on procedure, and demonstrate by example with my patient interactions that both the patient and the computer and its information are critical to healing.
Our computerized information systems, like an X-ray, are tools to probe more deeply into the patient and the cloud of information constructed around each of them. Analagous to physical findings and X-ray images, physicians need to integrate the computerized information into their healing approach to each patient. We're still finding our way as to the best way to do this, and to train the next generation in this skill.
(Excuse the poor quality of the photos -- I am a more skilled physician than I am a photographer)