Give emergency room physicians and staff resources that they can share with patients upon discharge, in the hopes of helping them find a longer-term solution to the health issue that led them to the ER. The project morphed to create a one-stop, easy-to-use resource for the Emergency Department, including the discharge navigation materials but also many more features, including quick guides on how to address many urgent problems that present themselves in emergency rooms.


Christopher “Toff” Peabody, MD, an emergency room physician with a background in consulting, leads ZSFG’s quality improvement work. He had helped start an Acute Care Innovation Center to bring technology into the Emergency Department, and worked with SOM Tech on two other projects because of the organization’s ability to build things on-site and without the red tape involved if they used an outside consultant.

Nick Stark, MD, MBA, started working with Peabody as a resident, and is now an associate physician and clinical instructor in Emergency Medicine and assistant director of the Acute Care Innovation Center.


The Acute Care Innovation Center received a grant in 2017 to explore ways to better connect patients with social resources throughout San Francisco.

Often, patients without stable health care come to a hospital’s emergency department, particularly the one at Zuckerberg San Francisco General Hospital and Trauma Center, needing urgent help. While the ER is a “heavily resourced space,” Stark said, it also deals only with the immediate issue, and staff doesn’t have the time to address all of a patient’s underlying health concerns.

Instead, once a patient is treated—hopefully for the better, Stark said—"we just put people back out. It’s like the Emergency Department is an island and the rest of the outpatient world is on the mainland, and we just put them in a boat and don't necessarily even give them an oar and just say, ‘Good luck.’”

“One thing we're trying to do is figure out how can we at least give patients an oar to help steer them in the right direction and help empower them to make that bridge between a highly-resourced acute care setting like the emergency department, and the rest of the healthcare world.”

This represented the local manifestation of a national problem, according to SOM Tech’s Cynthia Milionis, a UX (user experience) designer and culture lead. “Emergency departments were restructuring themselves throughout the U.S.,” Milionis said. “They are being overused by lots of people who aren’t insured.”

“The other problem we’re trying to address is, there are lots of services in the community, but people don’t know how to find them or access them, and instead they keep reappearing in the ER,” where they can take resources away from people who are truly in urgent need of care.

She noted that ZSFG is a training ground for residents who might be new to San Francisco and not know all the resources. And there were hundreds of resources, and they change all the time, so even experienced locals wouldn’t know everything. And the resources were not connected, and were not in the UCSF Health computer system.


The initial concept was to create a guide to services that staff could show patients in the Emergency Department, perhaps on specially outfitted iPads.

Through pilots of the program, the team learned quickly that iPads in the ER wouldn’t work, particularly for the targeted patients. “SOM Tech helped us understand our population,” Stark said. “Thirty percent of our patients don’t have access to a phone. Twenty-five percent don’t have access to safe housing.”

The tool would have to help medical professionals find the resources and steer the patients to them.

Milionis began spending time in the ER, following doctors, nurses and social workers to see them at work. She saw way too few social workers, with tremendous workloads, which meant that doctors needed to be prepared to direct patients to services.

Milionis led exercises with Peabody, Stark and others on the team, with scores of colored Post-Its getting pasted to boards with ideas. They made decision trees, working out how different cases should be handled. The process, known as “design thinking,” helps identify what’s needed.

They identified three priorities, often closely tied to each other: homelessness, substance abuse and mental illness.

The discharge sheets that the ER handed out at the time “were useless and not readable,” Milionis said. They were strictly in English, while many of the patients spoke only or mostly other languages. They gave legally required information, like children must be in a car seat, but very little practical information.

While work began before COVID spread, Milionis was in the ER working on the project on March 15, 2020, when shutdown orders came.

Although initially diverted because of the pandemic, work resumed. The pandemic demonstrated the need for a discharge navigator and so much more.

The project morphed, at first to make sure that clinicians and nurses knew the latest COVID protocols and guidelines. They took a complex list of 60 guidelines and generated a streamlined one-page document, Stark said.




Once the team saw how successful the COVID guidelines were, they resumed the project, expanding it to cover an even broader range of Emergency Department needs, from where to find necessary forms to recommending treatment options on the fly.

As it mushroomed, Milionis tried to keep the team focused on one guideline: Whatever they came up with had to be easy to use, and easy for residents and doctors to update.

When building a product packed with so much information, however, simplicity often gets buried. SOM Tech Deputy Director Beth Berrean “was really good, saying we need to simplify this,” Milionis said. “What we’re building is way too complicated for residents to ever take over, to ever update.”

“We tried to be really thoughtful and develop something that people would be able to use in real time,” Stark said. They started with many PDFs, four to eight pages long, that outlined procedures. You have someone who is super sick. You want the information that you need to keep that person safe immediately. No one ever going to read a six page PDF.”

“What we learned is that, for us in the acute care setting, we need something very straightforward,” Stark said. “We pared those PDFs down. Using residents and clinicians, we asked, ‘What are the core concepts here? How do we present this in a way that’s much more intuitive, and integrate it into the clinical setting in the way that people will use it?”

Residents and trainees—so-called digital natives—were the core of the team that designed E-Drive. Volunteer graduate students keep it up to date. It includes simple lists with links to a plethora of information that an ER employee might need. It also has a Google-like search, where people can type a keyword and go straight to what they need.

“SOM Tech helps us track our analytics, and we’ve had a 300-fold increase in users in the past 18 months,” Stark said.

In 2021, Urgent Matters, a collaborative network of emergency departments, named E-Drive a finalist for an Emergency Medicine Innovator of the Year Award. A video on the site explains E-Drive’s success.

Written by Dan Fost for SOM Tech (2022)


Homelessness Decision Tree