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IT Wizardry Streamlines Hospital Discharges, TOC

Jul 16, 2015
Wing Liu, Pharm.D.

Wing Liu, Pharm.D.

THE TRANSITION OF CARE (TOC) after hospital discharge remains perhaps the most vexing stage in the healthcare continuum. Lapses during patient hand-offs between the hospital and a patient’s home or a post-acute care facility often include incomplete information about key aspects of care. For pharmacy care, such breakdowns typically show up as multiple, conflicting, and erroneous medication lists.

At Vanderbilt University Medical Center (VUMC) in Nashville, Tenn., patient care during TOC has improved with the use of a new software program designed by Wing Liu, Pharm.D., product manager for the inpatient computerized physician order entry (CPOE) system, and his IT team.

“We asked ourselves, ‘How can we do a better job of coordinating all aspects of the transition to ensure patient care remains uninterrupted at a high level, regardless of where patients go?’” Dr. Liu said.

The Discharge Wizard app pulls together all elements of TOC into a single application.

The Discharge Wizard app pulls together all elements of TOC into a single application.

Rolled out in 2012, the Discharge Wizard application pulls together all elements of TOC into a single application, including the often daunting process of medication reconciliation.

The solution links directly to VUMC’s electronic health record (EHR), allowing clinicians to merge and exchange key information between the two IT platforms, such as patient demographics, follow-up appointments, patient core measures (e.g., congestive heart failure), healthcare team members, current medical status, bed location, and diet and exercise regimens.

The application even compels users to conduct medication reconciliation to complete the discharge process.

“It’s designed well and is easy to use,” said Amy Myers, Pharm.D., BCPS, a clinical pharmacist at VUMC.

“During the medication reconciliation process, the system allows you to choose, medication by medication, which to stop and which to continue. The result is a single, accurate medication list, which is also accessible through the EHR. That’s a huge benefit.”

Easy-to-Read Discharge Plan Streamlines Patient Handoffs

Ultimately, the system produces a discharge plan. All patients receive an easily readable discharge letter that includes medication schedules, follow-up appointments, additional care instructions, and educational material. For patients headed to a post-acute care facility, the plan is transmitted to the new healthcare providers via fax, email attachment, or with an accompanying paper record.

Nicole Callendar, R.N.

Nicole Callendar, R.N.

“One of the best features of this solution is the option to customize the discharge report based on the patient’s destination,” said Nicole Callender, R.N., staff nurse and support liaison for the application. “The orders tell the patient exactly what is needed for his or her care.”

To encourage rapid adoption of the Discharge Wizard application into the current discharge workflow, Dr. Liu wanted the app to be a model of simplicity. By all accounts, he succeeded.

Although the application is optional, biweekly utilization reports show that clinicians use it in about 95 percent of discharges. The most useful feedback about the system’s impact on workflow and patient care, he added, comes from anecdotal reports by users vs. quantitative measures.

Any member of the care team can easily launch the application through the CPOE, but only healthcare providers and select clinical pharmacists can save information. The software guides them through a sequence of fields to gather all of the relevant information needed for a discharge report. At any point, the process can be paused and restarted by another clinician, for example, in the case that a pharmacist needs to get involved in the medication reconciliation component.

Applicability to Post-Acute Care Facility Transfers

Originally, the Discharge Wizard applied only to patients discharged home. But a Centers for Medicare & Medicaid Services grant called “IMPACT: Improved Post-Acute Care Transitions” highlighted the need for an expanded role for the system to include patients transferred to post-acute care facilities. This is a patient group that is typically burdened by complex, mutable drug regimens.

Amy Myers, Pharm.D., BCPS

Amy Myers, Pharm.D., BCPS

“This is a very vulnerable population, especially for medication errors, yet it’s often excluded from TOC studies, which typically focus on patients going home,” Dr. Myers said. “It became apparent that we needed to improve our system for sending transfer orders to the new facility.” The more robust application went live in fall 2014.

Once VUMC nurses realized that using the software application meant they didn’t have to handwrite discharge orders anymore, and that patients could actually read the reports, they were sold, said Nicole Callender.

“Now, it’s part of the culture and widely embraced,” noted Callender. “It’s at the point where, if you’re a bedside nurse who doesn’t have a printed discharge letter from the Discharge Wizard to give to the patient, that nurse is going to call the provider to ask for it.”

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said that hospitals and health systems across the country need apps and systems like the Discharge Wizard to help reduce errors and improve medication reconciliation.

“It’s critical that TOC information is shared with all healthcare providers in a single location. This system is definitely a step in the right direction for healthcare technologies,” she added.

From the perspective of pharmacy informatics, the project has been eye opening, added Dr. Liu.

“As a pharmacist, I’ve been involved in creating an application for which my role was envisioning what it should do and how to get there,” he said. “It’s taken a team of four full-time software engineers working on it to get this far, and it’s been very gratifying to see the difference that it’s made for patients and healthcare providers alike.”

–By Steve Frandzel

Editor’s Note: The project described in this article was supported by Grant Number #1C1CMS331006 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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