Editor’s note: Second in a two-part series from SHM’s Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions. The first article appeared in the September issue of The Hospitalist.
Recommendation: Use EHR workflows to support discharge coaches.
David Ling, MD, is the chief medical information officer at Mary Washington Healthcare in Fredericksburg, Va. His team has applied Project Red functionality to use discharge coaches to improve transitions with EHR support. This intervention reduced readmissions to 7% from 11% from 2011 to 2012; there were no other initiatives during this time.
During this trial, a nurse functioned as discharge advocate, and clinical pharmacists called the patients within 72 hours of discharge. Nursing discharge advocates arranged follow-up appointments, reviewed medication reconciliation, and conducted patient education.
Patients were triaged to the service based on a diagnosis of heart failure, pneumonia, MI, or LACE (length of stay, acuity of admission, Charlson index [modified], number of ER visits in the last six months) risk stratification score greater than eight. The discharge advocate then reviewed prior encounters and determined educational needs.
Patient education was handled using care notes. The discharge advocate was the last person to review the discharge medication list. Pending labs were populated by the discharge advocate.
EHR support of this process required putting all of the discharge-related information in one spot in the EHR to make sure that all processes were completed by the multidisciplinary team prior to discharge.
—Noah Finkel, MD, FHM, Lahey Hospital and Medical Center
Patient-Centric Discharge Instructions
Recommendation: Support EHR build, create patient-centric multidisciplinary discharge paperwork.
At Lahey Hospital and Medical Center in Burlington, Mass., Noah Finkel, MD, and his colleague, Daniela Urma, MD, knew they had a problem with discharge. Paperwork and medication lists were incomplete and illegible. They knew they could not wait until the transition to Epic EHR to solve their problems.
In-house technical expertise created a program called “discharge assistant.” Discharge instructions are added to a common form for all members of the multidisciplinary team. A discharge medication list is imported at discharge from the outpatient EHR. The program allows the provider to note whether a medication is new, changed, or the same, and to add comments and indications to each medication. All of the standard elements of discharge planning are included (i.e., diet, wound care, return to work, diagnosis list, and who to call for specific problems).
The form cannot be completed and printed without all of the required elements included. The primary benefits of this program are legibility, completeness, and multidisciplinary data entry.
Coordination of Post-Discharge Appointments and Tests Prior to Discharge
Recommendation: Support coordination of care with electronic means of scheduling post-discharge care prior to discharge.
Aroop Pal, MD, FACP, FHM, program director of the Transitions of Care Services at the University of Kansas Medical Center in Kansas City, knows that there are many barriers to coordination of care with outside providers prior to discharge. If patients are discharged during normal business hours, the discharging provider may have to schedule these appointments and tests. A patient discharged after hours may be sent back to his or her PCP with a note requesting specific follow-ups.
Kansas University initiatives to improve scheduling have allowed its team to keep readmission rates below 13%, despite being the primary teaching hospital for the state of Kansas.
The process involved submission of scheduling requests, via EHR, to dedicated schedulers who would make the appointments in real time. The schedulers would notify the primary team, who would communicate with the patient. This system reduced the time to make the appointment and improved scheduler and physician satisfaction.
Medication Compliance after Discharge
Recommendation: Reduce technical and financial barriers to communication of medication list and medication compliance at home.
Sriram Vissa, MD, FACP, FHM, is medical director for informatics and co-practice group leader of the hospitalists for DePaul Hospital, SSM Healthcare, in Bridgeton, Mo. His hospital has improved medication compliance through improved medication reconciliation, improved clarity of discharge instructions, and better pharmacy integration. These interventions and others have reduced readmission rates to 12.81% at 30 days.
Barriers to compliance include procurement, financial issues, health literacy, clarity of instructions, medication lists to primary physicians, and patient portals. The EHR allows insurance integration to make sure that the patient can afford the prescribed medication An electronic connection to an on-site pharmacy makes sure that medications are delivered to the patient’s room prior to discharge. Medication lists are routed to PCPs via continuity of care functionality, which complies with meaningful use stage 2.
Also, the patient portal allows inpatient providers to ask questions about medications or discharge instructions.
Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass., and a member of SHM’s Health IT Committee.