Clinical Observation Epic Access and Medical Team Primer - HealthRex/CDSS GitHub Wiki

Clinical Observation

If you'd like to do some clinical observations (i.e. follow the medical team in Stanford hospital), you need clearance from SHC Privacy Compliance and Security Services.

Prerequisites

As a prerequisite, you'll need proof of (1) recent immunizations and (2) HIPAA training.

  1. Immunizations: You'll need proof from a medical provider of the following recent immunizations:
  • Varicella
  • Measles
  • Mumps
  • Rubella
  • Flu
  • Tuberculosis (screening test within the last year)
  1. HIPAA Training: Log into AXESS with your SUNet ID and password. Select the STARS (TRAINING). Use Search Catalog to find the course by name HIPAA/Protecting Patient Privacy or number PRIV-0010.

Paperwork and Badge Clearance

Once you've completed both, follow the steps below to complete the paperwork and get your badge.

  1. Complete anObserver Request Form. Use the following information:
  • Host: Dr. Jonathan Chen, Physician Data Scientist, Hospital Medicine
  • Department Chair/Division Chief: Dr. Neera Ahuja
  • Address: 300 Pasteur Drive, Stanford, CA 94305
  1. Email Privacy Compliance ([email protected]) and cc [email protected]:

I am a research assistant with Dr. Chen (cc'ed) in the Stanford Department of Medicine. Per the instructions on the Stanford Health Care volunteering page, I'm requesting permission to do clinical observation with in the hospital. Please let me know what documentation you need from me.

  1. Once your request has been approved, Privacy Compliance will ask you to turn in 3 more forms: (1) Visiting Observer Attestation, (2) Host Attestation, (3) Medical Clearance Form.
  • The Host Attestation requires signatures from both Dr. Chen and Dr. Ahuja. Give a blank form to Dr. Chen, who will get Dr. Ahuja's signature and return it to you.
  • The Medical Clearance Form requires a signature from Occupational Health Services. Take your medical forms to their office in room B09 on floor G of Stanford Hospital, and a nurse will review your paperwork within 15 minutes.

  1. Take your signed paperwork to Security Services in room B06 on floor G of Stanford Hospital. They'll take a photo and give you a badge granting access to the hospital patient areas for the next month. The line is always long, so budget 30-60 minutes.

  2. Email scanned copies of your signed paperwork to [email protected].

EPIC Access For Researchers

Students/researchers may find it useful to gain access to EPIC environments for projects that involve chart-review, CDSS implementation, or for a better understanding of what EHR data looks like from a clinician's perspective. Students and researchers can request EPIC access through the process outlined below.

If you are requesting access for an individual already within the SHC system, navigate to the website linked here and click on the Access Request. Specify whether you are requesting access for yourself or another individual, click the EPIC checkbox and submit the request.

If you are requesting access for an individual who is not in the system, navigate to the website linked here and click Onboarding Request. Fill in information for said individual, check the EPIC checkbox, select University Research Staff as in the user type drop down menu, and select Jonathan Chen from the Manager/SHC account Sponsor drop down menu. Submit the request.

Once approved, students/researchers will be able to access EPIC environments by navigating to the following site while on the university network: https://citrix.stanfordmed.org/. Relevant environments include

  • POC (proof of concept env - no real patient data exists in this environment)
  • SUPM (monthly refresh of EPIC)
  • SUPW (weekly refresh of EPIC)
  • Production (EPICs production env).

Login access to Epic to see what interface is like and facilitate chart review.

How Epic is requested and who can be granted access depends on the individual and their role.

Here’s some info for MD students who are working on faculty-led research projects or entering clinical rotations:
http://med.stanford.edu/md/student-affairs/life/epic.html

General info from the Department of Medicine:
https://domresources.stanford.edu/knowledge-base/sid-epic-access-hospital-log-in/
Division managers can help request access for research staff.

Primer Notes and Expectations for Medical Teams

Expectations

  • I will review H&Ps and Progress Notes before rounds, may text resident ~8am if helps early plans
  • Round at 9am
  • Discuss existing patients briefly within first half hour (sick or time-sensitive decisions, just updates and problem list/plans). See new patients together and present right in front of them. See old patients together when helpful. Let nursing station know when seeing patients or text message them plan after. Otherwise I'll start the group text with bedside nurse to FYI rounding and one liner summary of plan for the day. If seeing one intern's patient, okay for other intern to break off for orders, consults, etc.
  • Relevant (not comprehensive) Presentations (New: HPI = "The Story" -> A&P, Old: Events + Active Problem List)
  • Able to and expected to call and update senior/attending regularly (You're not "bothering" anyone. It's literally what we're paid for. Don't let other people throw you under the bus, trapped with sole liability, because they will)
  • Dispo Checklist: Reason for hospitalization, chief complaint, family on-board, meds/needs, transport, follow-up (Chief complaint: Beware that this is not always the same as the former, but if you ignore it, you're likely to see a bounceback)
  • Discharge setup day before: Work hard on NON call days. Day of discharge should be one button click.
  • Responsible for patient even after leaves (means you can let them go sooner)
  • Primary goal should be excellent patient care, but we should also be having fun. Clinical work is physically tiring and can be emotionally stressful, but we should feel like what we do matters and that we're in it together. If you're not feeling this way, let someone know.

(Intern) Tips

  • Use Voalte or if using SmartPage, then send copy to self (Keep a paper trail of messages sent and timestamps)
  • FYI pages / messages (Don't ask consultants for permission if they won't get back to you. Advise them what you will do and give them a deadline to intervene.)
  • Templates / Order Sets (See My SmartPhrases and other people with good templates to copy. E.g., I have several for common medical admission diagnoses)
  • Overnight Order History (Helpful way to confirm if anything happened to your patient overnight)
  • Admit Days: Sign-out ready by 6:50pm. Pagers transferred by 7pm. No interruptions, just wrap up H&Ps
  • White Coat Supplies: Consent Forms (Procedure+Blood Transfusion), Sterile Gloves, Gauze, Lube, Lidocaine, ABG Kit, Body Marker

Resident

  • Overnight Admits / Pre-Screen - Use to rebalance team (add or copy-paste in a Summary Line immediately, so that Rounding Reports will have a summary)
  • Only block if patient safety issue where cannot provide (surgical) service. If able to manage patient, don't worry too much, can always discharge or transfer patient later if need.
  • If (surgical) service trying to transfer to you, redirect to Medicine Consult Attending (https://medwiki.stanford.edu/display/hospitalmedicine/Interservice+Transfer+Policy+for+General+Inpatient+Medicine) which in turn may need to include Jeff Chi / Ashwin Nayak to juggle overall medicine admitting capacity
  • Integrate interns into admit triage / patient evaluation
  • Outside hospital transfers usually have transfer back agreement after specialty service completed
  • When called for ICU/CDU transfers, immediately get moving, don't need to stall with re-eval
  • When called for (ED) admits, run to eval patient immediately, not the computer When being paged/called, is always just a call for help. Admit is one solution, but callers happy as long as you're there to help resolve their problem one way or another
  • For borderline cases, I'm a fan of "observation" admits. Keeps everybody happy. Mostly just buys time to ensure no surprises with patient. If no surprises by the morning, makes for a quick discharge (means you're less likely to accumulate multiple complex, chronic cases).
  • Day shift admissions, let me know if you want to see or discuss on same day (or if need help triaging a concerning admission call). Otherwise good for resident autonomy to take first pass at plan. I'll be watching their charts in evening either way.

Med Students

  • See evaluation forms. End section has a good battery of "bonus items" to highlight student engagement.
  • MS3: Able to understand and engage in medical decision making discussions
  • MS4: Able to independently propose management plans (okay if they need to be corrected) and diligence to verify plans executed
  • Formal presentations of studies/teaching not as critical as demonstrating ability to use and apply these towards informing patient care decisions (having said that, I will pimp you on calculating PPV and NNT)
  • Engaged in responsibility for patient care, including both immediate and follow-up needs.
  • Having patient/family recognize you as a primary point of contact for the medical team (not that hard actually, if you just visit them an extra 1-2 times per day to provide them updates or call them after discharge to follow-up on concerns).
  • Rough heuristic: Look to next level up and aspire to "operate at the level of an X" or above

Admission

  • Med Rec at bedside with COW
  • H&P with COW at bedside. Soc Hx: Who do they live with, how did they get here, how are they getting back?
  • PT/OT for everyone by default, as often directs discharge
  • When they ask for attending name, I'm "Jonathan Hailin Chen" and for unclear reasons, I'm listed under Pediatrics.

Discharge Planning

  • Enter DC Orders day prior to DC (makes it easier to confirm meds and other needs available)
  • Call outpatient pharmacy to verify prescriptions and cost (or use discharge pharmacist)
  • FYI message to any consults (including outpatient physician if they directed for admission) before discharge to close loop on any additional recommendations.

Post-Discharge

  • DC Summary on day of discharge (if busy admit day, maybe defer one day, but no more)
  • Consider calling high risk patients few days after discharge
  • Whiteboard or pended note for labs to follow-up

Notes on Notes

  • Keep automatic SummaryLine updated everyday (background/ID, presenting picture, core assessment/diagnosis, core plan for treatment/dispo), then use to auto-fill your sign-outs, notes, etc.
  • Assessment & Plan: Don't need to copy-paste everything, every day. It's already stored in the prior medical record note. Strip down to just the active issues and questions of the day. (For many chronic issues, you could just say, continuing home meds XXX)
  • Don't repeat yourself (For example, don't write med doses unless there's a particular adjustment or point you're making. Med orders already have this info.)
  • Sign out is just for critical context and active events/issues that night team needs for quick context in the event of an emergency overnight call. Night team basically only cares about keeping the patient alive until the morning. If they need more detail, they will go to the medical record.
  • Don't copy X-ray, CT reports into notes. If want to, instead write a one liner summary of key findings. Exception: DC summary if going to non-Stanford docs, since they can't access our radiology reports
  • Prep a SmartPhrase for a "normal" physical exam, review of systems, and discharge instructions that you can easily drop in based on descriptions that are usually true (so rarely have to edit).
  • Documentation Clarifications: Just copy and paste one line to an addendum. Don't have to explain more.

Truisms

  • Assume sabotage? Or: Trust but verify
  • Don't go looking for trouble... enough trouble will come find you (Don't order diagnostics/tests unless essential)
  • Hospital is only for things that can only be done in the hospital
  • Case Manager matters more than Attending for discharge

More Resources Assorted tips and topic summaries from prior resident survival guides and notes on the MedWiki site:

  • medwiki.stanford.edu/display/medepic
  • medwiki.stanford.edu/display/dx
  • My Epic SmartPhrases (JONCxxx) provide quick A&P Templates for common medical issues
  • web.stanford.edu/~jonc101/tools/medTemplates.htm