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Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record.

ABSTRACT: The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platform on which standardization of content and format can be implemented. The feasibility of designing and implementing a standardized discharge summary hospitalwide using an EHR was examined-to the authors' knowledge, for the first time.This large-scale project at the University of Wisconsin Hospital and Clinics was led by a task force that had been assembled to develop best practices for EHR notes. The evidence-based Replicating Effective Programs (REP) model was employed to guide the development and implementation during the project. REP outlines four stages in clinical health service intervention implementation: preconditions, preimplementation, implementation, and maintenance.At 18 months postimplementation, 90% of all hospital discharge summaries were written using the standardized format. Hospital providers found the template helpful and easy to use, and recipient providers perceived an improvement in the quality of discharge summaries compared to those previously sent from the hospital.Discharge summaries can be standardized and implemented hospitalwide with both author and recipient provider satisfaction, particularly if evidence-based implementation strategies are employed. The use of EHR tools to guide clinicians in writing comprehensive discharge summaries holds promise in improving the existing deficits in communication at transitions of care.

SUBMITTER: Dean SM

PROVIDER: S-EPMC5367268 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record.

Dean Shannon M SM Gilmore-Bykovskyi Andrea A Buchanan Joel J Ehlenfeldt Brad B Kind Amy J H AJ

Joint Commission journal on quality and patient safety 20161216 12

<h4>Background</h4>The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platfo ...[more]

PMID: 28334559

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Project description:BackgroundObtaining accurate clinical information about recent acute care visits is extremely important for outpatient providers. However, documents used to communicate this information are often difficult to use. This puts patients at risk of adverse events. Elderly patients who are seen by more providers and have more care transitions are especially vulnerable.ObjectiveThis study aimed to (1) identify the information about elderly patients' recent acute care visits needed to coordinate their care, (2) use this information to assess discharge summaries, and (3) provide recommendations to help improve the quality of electronic health record (EHR)-generated discharge summaries, thereby increasing patient safety.MethodsA literature review, clinician interviews, and a survey of outpatient providers were used to identify and categorize data needed to coordinate care for recently discharged elderly patients. Based upon those data, 2 guidelines for creating useful discharge summaries were created. The new guidelines, along with 17 previously developed medical documentation usability heuristics, were applied to assess 4 simulated elderly patient discharge summaries.ResultsThe initial research effort yielded a list of 29 items that should always be included in elderly patient discharge summaries and a list of 7 "helpful, but not always necessary" items. Evaluation of 4 deidentified elderly patient discharge summaries revealed that none of the documents contained all 36 necessary items; between 14 and 18 were missing. The documents each had several other issues, and they differed significantly in organization, layout, and formatting.ConclusionsVariations in content and structure of discharge summaries in the United States make them unnecessarily difficult to use. Standardization would benefit both patients, by lowering the risk of care transition-related adverse events, and outpatient providers, by helping reduce frustration that can contribute to burnout. In the short term, acute care providers can help improve the quality of their discharge summaries by working with EHR vendors to follow recommendations based upon this study. Meanwhile, additional human factors work should determine the most effective way to organize and present information in discharge summaries, to facilitate effective standardization.

Project description:ObjectiveCommon data elements (CDEs) are standardized questions and answer choices that allow aggregation, analysis, and comparison of observations from multiple sources. Clinical CDEs are foundational for learning health care systems, a data-driven approach to health care focused on continuous improvement of outcomes. We aimed to create clinical CDEs for pediatric epilepsy.MethodsA multiple stakeholder group (clinicians, researchers, parents, caregivers, advocates, and electronic health record [EHR] vendors) developed clinical CDEs for routine care of children with epilepsy. Initial drafts drew from clinical epilepsy note templates, CDEs created for clinical research, items in existing registries, consensus documents and guidelines, quality metrics, and outcomes needed for demonstration projects. The CDEs were refined through discussion and field testing. We describe the development process, rationale for CDE selection, findings from piloting, and the CDEs themselves. We also describe early implementation, including experience with EHR systems and compatibility with the International League Against Epilepsy classification of seizure types.ResultsCommon data elements were drafted in August 2017 and finalized in January 2020. Prioritized outcomes included seizure control, seizure freedom, American Academy of Neurology quality measures, presence of common comorbidities, and quality of life. The CDEs were piloted at 224 visits at 10 centers. The final CDEs included 36 questions in nine sections (number of questions): diagnosis (1), seizure frequency (9), quality of life (2), epilepsy history (6), etiology (8), comorbidities (2), treatment (2), process measures (5), and longitudinal history notes (1). Seizures are categorized as generalized tonic-clonic (regardless of onset), motor, nonmotor, and epileptic spasms. Focality is collected as epilepsy type rather than seizure type. Seizure frequency is measured in nine levels (all used during piloting). The CDEs were implemented in three vendor systems. Early clinical adoption included 1294 encounters at one center.SignificanceWe created, piloted, refined, finalized, and implemented a novel set of clinical CDEs for pediatric epilepsy.

Project description:Although standardized terminologies such as the International Classification of Diseases have been in use in medicine for over a century, efforts in the dental profession to standardize dental diagnostic terms have not achieved widespread acceptance. To address this gap, a standardized dental diagnostic terminology, the EZCodes, was developed in 2009. Fifteen dental education institutions in the United States and Europe have implemented the EZCodes dental diagnostic terminology. This article reports on the utilization and valid entry of the EZCodes at three of the dental schools that have adopted this standardized dental diagnostic terminology. Electronic data on the use of procedure codes with diagnostic terms from the three schools over a period from July 2010 to June 2011 were aggregated. The diagnostic term and procedure code pairs were adjudicated by three calibrated dentists. Analyses were conducted to gain insight into the utilization and valid entry of the EZCodes diagnostic terminology in the one-year period. Error proportions in the entry of diagnostic term (and by diagnostic category) were also computed. In the twelve-month period, 29,965 diagnostic terms and 249,411 procedure codes were entered at the three institutions resulting in a utilization proportion of 12 percent. Caries and periodontics were the most frequently used categories. More than 1,000 of the available 1,321 diagnostic terms were never used. Overall, 60.5 percent of the EZCodes entries were found to be valid. The results demonstrate low utilization of EZCodes in an electronic health record and raise the need for specific training of dental providers on the importance of using dental diagnostic terminology and specifically how to use the terms in the electronic record. These findings will serve to increase the use/correct use of the EZCodes dental diagnostic terminology and ultimately create a reliable platform for undertaking clinical, outcomes, and quality improvement-related research.

Project description:ObjectiveTo evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.Materials and methodsEnglish-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.ResultsOf 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of -16.1% (9.6), P = .09).ConclusionsEHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.Trial registrationNIH US National Library of Medicine, NCT03116074, clinicaltrials.gov.

Project description:BackgroundThe predominant implementation paradigm of electronic health record (EHR) systems in low- and middle-income countries (LMICs) relies on standalone system installations at facilities. This implementation approach exacerbates the digital divide, with facilities in areas with inadequate electrical and network infrastructure often left behind. Mobile health (mHealth) technologies have been implemented to extend the reach of digital health, but these systems largely add to the problem of siloed patient data, with few seamlessly interoperating with the EHR systems that are now scaled nationally in many LMICs. Robust mHealth applications that effectively extend EHR systems are needed to improve access, improve quality of care, and ameliorate the digital divide.ObjectiveWe report on the development and scaled implementation of mUzima, an mHealth extension of the most broadly deployed EHR system in LMICs (OpenMRS).MethodsThe "Guidelines for reporting of health interventions using mobile phones: mobile (mHealth) evidence reporting assessment (mERA)" checklist was employed to report on the mUzima application. The World Health Organization (WHO) Principles for Digital Development framework was used as a secondary reference framework. Details of mUzima's architecture, core features, functionalities, and its implementation status are provided to highlight elements that can be adapted in other systems.ResultsmUzima is an open-source, highly configurable Android application with robust features including offline management, deduplication, relationship management, security, cohort management, and error resolution, among many others. mUzima allows providers with lower-end Android smartphones (version 4.4 and above) who work remotely to access historical patient data, collect new data, view media, leverage decision support, conduct store-and-forward teleconsultation, and geolocate clients. The application is supported by an active community of developers and users, with feature priorities vetted by the community. mUzima has been implemented nationally in Kenya, is widely used in Rwanda, and is gaining scale in Uganda and Mozambique. It is disease-agnostic, with current use cases in HIV, cancer, chronic disease, and COVID-19 management, among other conditions. mUzima meets all WHO's Principles of Digital Development, and its scaled implementation success has led to its recognition as a digital global public good and its listing in the WHO Digital Health Atlas.ConclusionsGreater emphasis should be placed on mHealth applications that robustly extend reach of EHR systems within resource-limited settings, as opposed to siloed mHealth applications. This is particularly important given that health information exchange infrastructure is yet to mature in many LMICs. The mUzima application demonstrates how this can be done at scale, as evidenced by its adoption across multiple countries and for numerous care domains.

Project description:BackgroundClinical prediction rules (CPRs) represent a method of determining individual patient risk to help providers make more accurate decisions at the point of care. Well-validated CPRs are underutilized but may decrease antibiotic overuse for acute respiratory infections. The integrated clinical prediction rules (iCPR) study builds on a previous single clinic study to integrate two CPRs into the electronic health record and assess their impact on practice. This article discusses study design and implementation of a multicenter cluster randomized control trial of the iCPR clinical decision support system, including the tool adaptation, usability testing, staff training, and implementation study to disseminate iCPR at multiple clinical sites across two health care systems.MethodsThe iCPR tool is based on two well-validated CPRs, one for strep pharyngitis and one for pneumonia. The iCPR tool uses the reason for visit to trigger a risk calculator. Provider completion of the risk calculator provides a risk score, which is linked to an order set. Order sets guide evidence-based care and include progress note documentation, tests, prescription medications, and patient instructions. The iCPR tool was refined based on interviews with providers, medical assistants, and clinic managers, and two rounds of usability testing. "Near live" usability testing with simulated patients was used to ensure that iCPR fit into providers' clinical workflows. Thirty-three Family Medicine and General Internal Medicine primary care clinics were recruited at two institutions. Clinics were randomized to academic detailing about strep pharyngitis and pneumonia diagnosis and treatment (control) or academic detailing plus use of the iCPR tool (intervention). The primary outcome is the difference in antibiotic prescribing rates between the intervention and control groups with secondary outcomes of difference in rapid strep and chest x-ray ordering. Use of the components of the iCPR will also be assessed.DiscussionThe iCPR study uses a strong user-centered design and builds on the previous initial study, to assess whether CPRs integrated in the electronic health record can change provider behavior and improve evidence-based care in a broad range of primary care clinics.Trial registrationClinicaltrials.gov ( NCT02534987 ).

Dataset Information

Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record.

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Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record.

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