When the internist known as "Dr. Lyle" isn't seeing patients at his Chicago-based primary care practice, he is directing the Szollosi Healthcare Innovation Program, a nonprofit incubator he co-founded in 2007 to develop healthcare technologies and IT tools for clinical use. An Associate Professor of Medicine at the Feinberg School of Medicine at Northwestern University, Dr. Lyle is also an expert in health informatics and has authored numerous articles on the topic. He likes technology, a lot.

ExpectED is the first project to come out of the Szollosi program (SHIP). Berkowitz came up with the idea for replacing doctors’ handwritten "expect notes" based on his experiences sending patients the emergency room at Northwestern Memorial Hospital. Dr. Berkowitz’s primary care practice is the largest in the Chicago area and he is known to his peers in the Northwestern ER as a “large volume referrer.”

Berkowitz had grown frustrated with the old method: he'd make a phone call to a triage doctor or nurse who would then take down notes on the expected patient. (Hence, the term “expect note.”) But by the time Berkowitz’s patient arrived at the ER, often hours later, these handwritten notes were sometimes misplaced or even attached to the wrong chart.

“ER's are chaotic places and little slips of paper are bound to get lost,” Dr. Berkowitz says. Time diverted or wasted trying to recover information on a patient by hunting a paper trail or by calling a referring doctor again, comes at cost.

“When I have to stop treating one patient to take an expect note on another the quality of information is degraded,” says Dr. Martin Lucenti, Vice Chair of Clinical Operations at Northwestern, and Dr. Berkowitz’s collaborator on ExpectED. “Ours is a system where delaying person only delays the next. So anything you can do to help the patient in front of you, to make it more efficient, allows you to [work] better and faster -- with better outcomes."

In April 2008, the pair launched a beta test of ExpectED, limited to physicians in Dr. Berkowitz’s practice and urgent care staff in Dr. Lucenti’s ER. Version 1.0 is a simple, web based application. A referring doctor logs into ExpectED’s secure site and creates a new note with the patient’s DOB, location of the recent evaluation and expected arrival time at the ER. The substantive data is in the SBAR section (“situation, background, assessment and recommendation”), where existing conditions, meds and the referring doctor’s opinion is recorded. Referring docs also include their “preferred consultants,” specialists’ names should any become necessary.  (Screenshot at left, below.)

The one-page forms are electronically stored, but in version 1.0, they cannot be pulled off the web at the ER. ExpextED faxes them to an urgent care desk where they are printed and filed by a nurse.  (Screenshot at right, below.) It’s not ideal, as it still uses paper. But there are no more time-hording phone calls or error-prone scribbles.

"It was a big process improvement, because it took the doctor out of the information exchange system," says Michael Schmidt, the current Medical Director of the Emergency Unit at Northwestern Memorial. Keeping doctors at the bedside matters in an ER like Northwestern’s, where, at peak volume, five attending physicians and 22 nurses will treat between 240 and 290 patients in a 24-hour period. Imagine the amount of data flowing through Dr. Schmidt’s ER at peak traffic. Getting the correct and prioritized information on a patient to the doctor at the moment when it is most valuable—as the patient is being examined, rather than hours before—is the difference between good care and sub-par care.

This kind of information allocation requires high quality but asynchronous communication, which isn’t easy to achieve in a low-stress environment. (Think of the game telephone.) ExpectED makes high quality asynchronous communication between doctors just a bit easier.

“Now we get information from a primary care doctor when we want it and it we convey information [back] to them at our best time. They don’t have me calling them at 4 AM asking 'what do you think and why are you sending this patient to me?’” Dr Lucenti explains.  Sending and accessing information when it is most relevant saves time and prevents errors.

In one recent case, a patient presented to his primary care doctor with extreme chest pain. An EKG indicated acute heart attack. From reading that expect note Dr. Lucenti mobilized the cath lab at the hospital ahead of time. “Essentially we started the whole process to open up his artery before we even saw the patient.  We got him into the lab in rapid progression. It saved him as much as 30 min or an hour.” It also likely saved his life.

Dr. Berkowitz now building out ExpectED 2.0: a version to integrate directly with Northwester’s EMR system, so nurses will no longer need to print faxed versions of ExpectED notes, and the substantive data will flow directly into the patient’s complete medical record. He says referring physicians ought to be able to create ExpectED notes from within the EMR itself, or through the original web interface – meaning even physicians not on Northwester’s Cement-based EMR could still use ExpectED when sending patients to the ER.

ExpectED 2.0 will be ready by the end of September, and soon after, also available to non-Northestern Memorial physicians. It will be compatible with many, but not all, EMR systems.

"If you have a widely available EMR  in both your outpatient and ER settings (Cerner, Epic, Allscripts, or NextGen), then it makes sense to go right to our Phase 2 and create notes that post right into the viewing window the ER docs will see,” Dr. Berkowitz says. “If your EMR is not in both settings, Phase 1 will still be helpful (web based notes that print out in the ER).”

Dr. Berkowitz made the web based version open source, so other physicians and developers may build upon them to meet their particular needs. If you’d like to try ExpectED Phase I, simply email Dr. Berkowitz directly, and he’ll send you the code.  lyle@drlyle.com