Department of Pathology & Laboratory Medicine, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
Department of Pathology & Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, GA, USA.
Vox Sang. 2020 Jul;115(5):443-450. doi: 10.1111/vox.12913. Epub 2020 Mar 20.
The Joint Commission lists improving staff communication (handoffs) as part of several National Safety Goals. In this study, we developed an electronic web-based charting system for clinical pathology handoffs, which primarily consist of transfusion medicine calls, and evaluated the advantages over a paper-based handwritten call log.
A secure online web browser application using Research Electronic Data Capture (REDCap) was designed to document on-call pathology resident consults. A year after implementation, an online survey was administered to our pathology residents in order to evaluate and compare the usability of the electronic application (e-consults) to the previous handwritten call log, which was a notebook where trainees hand wrote different components of the consult.
The REDCap web-based application includes discrete fields for patients' information, requesting physician contact, type of consult, action items for follow-up and faculty responses, as well as other information. These components have eventually progressed to be an online consult call catalog. With approximately 1079 consults per year, transfusion medicine-related calls account for ~90% of the encounters, while clinical chemistry, microbiology and immunology calls constitute the remainder. The overall response rate of the survey was 96% (29 of 30 participants). Of the 16 respondents who experienced both call log systems, 100% responded that REDCap was an improvement over the handwritten call log (P < 0·0001).
E-consult documentation entered into a web-based application was a user-friendly, secure clinical information access and effective handoff system as compared to a paper-based handwritten call log.
联合委员会将改善员工沟通（交接班）列为几项国家安全目标之一。在这项研究中，我们开发了一种用于临床病理交接班的电子网络图表系统，主要包括输血医学呼叫，并评估了其相对于基于纸质手写呼叫日志的优势。
使用 Research Electronic Data Capture（REDCap）设计了一个安全的在线网络浏览器应用程序，用于记录值班病理住院医师的咨询。实施一年后，我们向病理住院医师进行了在线调查，以评估和比较电子应用程序（电子咨询）与之前手写呼叫日志的可用性，后者是一个笔记本，学员在其中手写咨询的不同部分。
REDCap 基于网络的应用程序包括患者信息、请求医生联系、咨询类型、随访行动项目和教职员工回复等离散字段，以及其他信息。这些组件最终演变为在线咨询呼叫目录。每年约有 1079 次咨询，输血医学相关呼叫占~90%的就诊，而临床化学、微生物学和免疫学呼叫构成其余部分。调查的总体回复率为 96%（30 名参与者中的 29 名）。在体验过两种呼叫日志系统的 16 名受访者中，100%的人表示 REDCap 优于手写呼叫日志（P<0·0001）。
与基于纸质的手写呼叫日志相比，电子咨询文档输入基于网络的应用程序是一种用户友好、安全的临床信息访问和有效的交接班系统。
