Background: Documentation shortcut tools in electronic health records, such as dot phrases, are essential in a busy clinical environment to promote efficiency and standardize care, but are known to carry risks. The extent to and mechanism by which dot phrase errors occur are poorly characterized. In addition, there are no defined interventions for hospitalists to address them once identified.
Purpose: We sought to develop a durable model to address patient safety reports of errors in patient instructions populated by dot phrases. This included identifying key stakeholders, assessing the extent of the problem, understanding EHR capabilities and limitations, and designing an intervention to mitigate risks.
Description: The clinical coordinator for the hospitalist group noticed an increased number of calls from patients discharged from non-hospitalist services with clinical questions. Puzzled by this trend, he raised his concern to hospitalist leadership. Each of the impacted patients were given the same phone number in the free-texted section of the discharge instructions.Given the similarities in instructions, the hospitalist informaticists suspected that the phone number was likely embedded in a custom dot phrase that was shared with providers outside of the hospitalist service. Each of the discharging provider’s custom dot phrases were reviewed and found to contain the same dot phrase that originated from an internal medicine resident who had already graduated. It had since been shared with 96 users. A more exhaustive search with the help of an EHR analyst found an additional 277 unique dot phrases containing this phone number, saved in 350 user accounts. It appeared that the dot phrase, with its embedded hospitalist phone number, had gone viral. The team explored both technical and operational solutions, including messaging all clinical services to manually review and update contact information in the discharge instructions, targeted messaging to users who had the phone number saved in their library, deletion of all affected dot phrases, and replacement of the phone number in the dot phrases. Each of the potential solutions carried risks. Given the precedent setting nature of any intervention to overwrite users saved custom dot phrases, careful deliberation was undertaken with hospital leadership input. We sought to balance the right of individual users to create and maintain custom dot phrases with the need to prevent some users from inadvertently using the dot phrases in the incorrect context. It was ultimately decided that replacing the hospitalist phone number with a central hospital call center number designed for handing post-discharge questions would be least disruptive to both patient experience and provider workflow, with the potential to reduce delays in care.
Conclusions: The ease with which users can create, share, borrow, and adapt content through a documentation shortcut tool propagated this error beyond users who had rotated through a single hospital service. This is the first known case of a dot phrase appropriately created for one setting, adapted by others for another, and that through sharing caused widespread error propagation that impacted patient care. The clinical coordinator within this high functioning hospitalist group was able to quickly identify the pattern and bring the issue to attention and ultimately, a resolution. Hospitalists are critical in the analysis of safety events that involve the EHR and the design of interventions to mitigate those hazards before they cause further harm.