Information, Data Entry, and Reporting Requirements for a Resident Handoff of Care Support Tool Ellen J. Bass 1 , Senior Member, IEEE, Kimberly Brantley 2 , Thomas Perez 3 , Matthew L. Bolton 4 , Adam Helms 5 , Luther Bartelt 6 , Rick Hall 7 , George Hoke 6 , Margaret Plews-Ogan 6 , Linda Waggoner-Fountain 8 , Stephen Borowitz 8 1 College of Information Science and Technology, College of Nursing and Health Professions, Drexel University 2 Accruent 3 SRA International 4 Department of Mechanical & Industrial Engineering, University of Illinois at Chicago 5 Department of Internal Medicine, University of Michigan Health System 6 Department of Medicine, University of Virginia 7 Lee Moffitt Cancer Center 8 Department of Pediatrics, University of Virginia Abstract— Physician handoff of care is a mechanism for transferring patient information, responsibility, and authority from one set of caregivers to another. At shift change at a hospital, residents going off shift handoff patients to those coming on shift. There are limited handoff of care tools that facilitate the handover process by condensing patient information in reports that can be referenced during the handoff of care and used during patient care as cognitive artifacts. This effort works to address information, data entry and reporting requirements for a resident handoff of care tool that would support transfer of information as well as patient care. Keywords- continuity of care transitions, communications, quality improvement, patient safety, sign-out, handover, shift change I. INTRODUCTION Improved automation such as health information technology may improve patient safety and healthcare quality as it can support human judgment and decision making processes [6]. However, it can impacts health care providers’ physical and cognitive workflows by changing the way activities are carried out and therefore can create new classes of problems related to the coupling and dynamic interleaving of humans and automated systems. At shift change, medical residents going off shift handover patient responsibility and authority to those coming on shift. Handoff of care tools have been shown to help reduce the number of patients missed on rounds and the number of adverse events [11][13][17][23] although they depend on the timely and accurate data entry [15]. Tools also offer the ability to print patient information into different types of reports used as a reference during handoff of care and when providing patient care [5][21]. Tools have also contributed to satisfaction with handoff quality [17] and efficiency in the amount of time pre-rounding and rounding [17][23] as well as the amount of time spent at the patient bedside [23]. There is no coherent set of requirements for these tools with respect to the data elements to include for data entry and reporting. In this effort an operational concept of tool was defined based on literature about sign-out, observations of subject matter experts, surveys, and an appreciative-inquiry process (where exemplar residents met as a group, and a list of practices for each of the residents was created and areas of overlap identified)[12]. Requirements included the appropriate data elements and functionality for data entry, manipulation, and printing. Evaluation was performed via field-testing a set of prototype tools, and determining if the requirements met the needs of the residents with a combination of observations from residents, surveys and review of logged data. II. OPERATIONAL CONCEPT The primary role of a handoff of care tool is to help facilitate the handover process. A secondary role is to support patient care post-handover. For patients in a resident’s patient list, the tool should scaffold data entry for the information pertinent to sign-out. The literature describes general categories of patient information for supporting handoff of care (Table 1). A resident must be able to view and modify data for his or her patients. A resident should be able to populate a patient list by adding new patients, reassigning existing patients from other residents, or retrieving data previously stored. However, the tool should not pull certain data elements such as the current condition from prior hospitalizations, as it may not be relevant to the current situation. In addition, the tool should not pull medications, acuity, tasks, and some administrative information such as location from the patient’s archived information when the patient is readmitted. Residents prefer to have a paper artifact to support the handoff of care process as well as patient care [5][8][11][20][22][24]. The printed report should format the information to support the handoff of care process (Table 2). For example, all of a patient’s data should fit on one sheet of paper and not be across multiple sheets. Requiring this specific report format helps a resident not miss any patient information because it was on a separate page. Residents may wish to control the order in which patients appear in the report. One way to sort is by acuity with the sickest patients first [2][10]. If something interrupts the handoff of care session and it cannot resume, the residents will have already discussed the sickest patients. 2013 IEEE International Conference on Systems, Man, and Cybernetics 978-1-4799-0652-9/13 $31.00 © 2013 IEEE DOI 675 2013 IEEE International Conference on Systems, Man, and Cybernetics 978-1-4799-0652-9/13 $31.00 © 2013 IEEE DOI 10.1109/SMC.2013.120 675