How are your sitting? Learning from open note…
I am sitting in clinic. The desk with the computer that runs a version of Windows which is sought avidly by technology museums worldwide stands in front of me. The patient, who is clearly expecting unpleasant news is sitting next to the desk with his daughter.
In front of me, open, the large file. I am trying to keep track and dot down keywords of what we are discussing while maintaining eye contact with the patient and his daughter. In order to explain the problem in the lungs I am brining up the X-rays on the screen. I twist the computer screen as far as the short wire allows, so that the patient is able to appreciate the anatomy and how this might have affected the recent breathlessness.
I sometimes write a couple of lines on a piece of paper for the patient: the name of the diagnosis, the treatment, whom to contact. Not a lot. Then the patient leaves. I complete the notes, dictate a short letter and get the next file.
What I document in the consultation on paper and as a letter is key strategic information that allows me and my colleagues to pick-up at the next appointment what I thought was the likely cause for the problem that the patient presented with, the tests that are needed to confirm this and suggestions for treatment. More often then not documentation feels like a burden, a non-value added step that should be somebody else’s job. Much gets lost or might have accidental errors, a problem that becomes only apparent during complaints or legal cases. This is when doctors regret that they have not taken more time (that they did not have) to document what and what not they thought and said.
David Thorisson is an Emergency Physician who works in Sweden. He disagrees. In his electric world notes become a swift and crucial part of safety, especially for handover and other issues of patients safety. And he is right: If something goes wrong it is nearly always linked to flow of information. And the place where this information is held are the clinical records. (http://pricelesselectricalactivity.blogspot.co.uk/2013/07/doctors-should-write-more-medical-notes.html).
Leana Wen is a Boston Emergency Room resident who is sharing a related experience on her blog. Like me she encounters a patient, they sit on opposing sides of the computer screen, and at some point the patient asks to see the notes she is typing. She can’t turn the screen so the patient comes around the table. Now they are sitting next to each other. Working together on that screen. Doting down key information, remove incorrect entries. And the diagnosis becomes apparent. (http://www.npr.org/sections/health-shots/2014/08/14/340351393/when-patients-read-what-their-doctors-write).
I have been trying to reflect on her experience. For projects where time is of the essence and we need to get results we often sit together and work off a single screen. Pair programming (sometimes called power programming) is a way to write code with one person coding and the other checking with regular switches between the roles. The fact of sitting next to each other with the notes in front might imply less hierarchy. Form shaping function.
In order to facilitate the transition to a more symmetrical partnership between patients and doctors Jan Walker and Tom Delbanco thought along similar lines when they embarked on building OpenNotes. OpenNotes is a a software platform that allows patients to review their doctors records. And interestingly in related research this is something that 80% of patients want to at least explore, test once. (http://www.bmj.com/content/350/bmj.g7785).
Does this change what doctors do? It probably does change the way that doctors record their thoughts. It might take a bit more time, but if the notes are better quality then handoff and related functions might actually improve safety. Bingo, form shaping function.
Time consuming? Stress full for doctors? You bet! But Peter Elias, a medical OpenNote user is brazen: “Few consultants complained that they are getting pressure from my patients to do the same. I simply said, tell me if it is a big problem and I will send my patients elsewhere. That was the end of it.”(http://www.kevinmd.com/blog/2014/07/physician-responds-opennotes-critics.html)
So what will be the effects of new shapes of working on
the environment in which they are deployed?
the behaviour of those working differently?
patient related outcomes ?