The Hospital Discharge Process: A Call for Technology’s Help?

While being discharged from the hospital even after a minor procedure is not simple (due to regulatory documentation requirements often hard for both patients and physicians to sift through), the process for a patient with co-morbidities after a prolonged stay is daunting.  There are physicians from multiple specialties, various non-physician providers, social worker, and the case manager, all of whom address different discharge-related issues.  It is frustrating for both a provider and patient to experience the “I really can’t answer that question” moment. Lack of effective interdisciplinary communication may lead to medical errors, and either premature or delayed discharges. The date of discharge is estimated soon after admission. Some hospitals have a focus on the clock when planning discharges. If planning occurs too early, it does not account for changes in patient needs and wrong instructions might be given. Transportation and home aid needs are time-sensitive. In contrast, some planning needs to be considered early in the admission when discharge to a non-acute care facility is obvious due to the diagnosis and/or social situation of the patient. One recent study in JAMA from the Brigham and Women’s Hospital identified seven clinical factors predicting hospital readmission: a hemoglobin less than 12 g/dL on discharge, discharge from an oncology service, low serum sodium level on discharge, a procedure (via ICD-9 standards) during admission, non-elective admission, length of stay > 4 days, and number of admissions during the previous year.  Another study examined many predictive models found in the literature.  “Of 7843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability…Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization …, and 5 could be used at hospital discharge…” The study’s conclusion was that most prediction models perform poorly or require improvement. Perhaps one reason for this result lies in the fact that these models traditionally either fall into a clinical or administrative model. I believe that better success might be achieved if administrative and clinical predictive models are combined. Better analytics programs applied real-time in the EHR will facilitate integration of these  perspectives.

The topic of transitional care has received attention because a poor discharge process results in higher readmission rates, a new benchmark focus of Medicare. Hospitals might be very good at meeting regulatory requirements  but the patient’s understanding of diagnoses and instructions (both care and follow-up) is often not clear.  Though required via regulations, the caregiver may not even be included in the process.  I will discuss areas which can benefit from technology. Some of the technology mentioned below might not necessarily be available in the context described but feasible.

  1. Durable equipment needs: The care coordinator is generally the point person regarding the patient’s durable equipment needs upon discharge. Ordering the equipment (specifications and date, time, and place of delivery) might be the job of someone else (therapist, physician). Digital tools can expedite equipment procurement. Analytics from the EHR (mining diagnoses, equipment in use at the end of the hospitalization, expected place of transition, etc) might determine the individual’s ambulation, oxygen, bed, or other equipment requirements. This can act as a preliminary checklist from which the coordinator can start, rather than personally going through the EHR or surveying providers. A digital ordering program can directly interact with the distributor to check product availability and verify delivery. Another useful tool would aggregate equipment distributors which are stratified according to certification (Medicare bidding approval status), cheapest price, and best rated service (by patients and/or institutions).
  2. Visiting nurses: Often the home needs assessment for visiting nurses is done once the patient is discharged. This can be expedited with the help of a caregiver with the assessment completed in the hospital. Consider a tool into which the physician’s orders or recommendations for home nursing are placed and shared with the visiting nurse entity, the patient, and the caregiver. It would include the nursing assessment, and a video of the home environment (a factor in the assessment itself). This would obviate the need for a dedicated assessment visit. Visiting nurses themselves should be equipped with mobile technology which would: document their time schedule for billing, interventions, record and transmit vital signs (measured via digital remote monitors), orders, and contain a digital messaging program.
  3. Scheduling of outpatient provider appointments: Although there is some evidence that in a general medical population early follow-up appointments do not impact readmission rates(notwithstanding a slightly higher emergency department visit and death rate), some patient including those with congestive heart failure  have been shown to benefit from early follow-up. The success of a growing number of commercially available mobile apps intended to streamline scheduling of physician appointments is testimony to the need it is addressing in the non-acute setting.  Patient portal use is a requirement of EHR’s Meaningful Use Stage 2. One way of encouraging patient participation in portal use would be activating it by utilizing a discharge planning scheduling application of the portal at the time of discharge. This fits into an overall strategy of point of engagement implementation of technology.

These are only a few highlights of the complexity of the discharge process. All physicians have dealt with the many questions, complications, and frustration experienced by patients after discharge. A failed process creates unnecessary work, expense and bad outcomes.  Digital health technology’s image to many physicians is represented by the EHR in its present form, which is not what the doctor ordered. It is not intuitive, cumbersome, and encourages impersonal encounters with patients. I will explore in future posts how digital technologies other than the EHR will change medicine in ways that physicians will appreciate them.

About davidleescher

David Lee Scher, MD is Founder and Director at DLS HEALTHCARE CONSULTING, LLC, which specializes in advising digital health technology companies, their partners, investors, and clients. As a cardiac electrophysiologist and pioneer adopter of remote patient monitoring, he understood early on the challenges that the culture and landscape of healthcare present to the development and adoption of digital technologies. He is a well-respected thought leader in mobile and other digital health technologies. Scher lectures worldwide on relevant industry topics including the role of tech in Pharma, patient advocacy, standards for development and adoption, and impact on patients and healthcare systems from clinical, risk management, operational and marketing standpoints. He is a Clinical Associate Professor of Medicine at Penn State College of Medicine.
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4 Responses to The Hospital Discharge Process: A Call for Technology’s Help?

  1. The problem is fumbled hand offs n general, discharge planning being only one.

  2. Philip Taylor says:

    As always Dr Scher, thank you for sharing this article.
    While not educated to the degree in which you are, please forgive me if my observations seem sophmoric on the matter.
    But, in my opinion the EHR companies have become more interested in filling existing roles and definations of need or desire in the medical community than trying to innovate them.
    In my opinion, regarding electronic records- the health community as a whole is behind nearly two decades. All of our life savings, retirement, trading, and business as a whole has been electronic in its records systems for decades. Airline industries have been carrying a persons most guarded parts of personal information electronically for nearly 30 years (upgrading to windows formatted computers in 2004 vs their pre dos legacy systems world wide). Health systems and electronic management have only recently started dancing together and thats mostly due to goverment mandates.
    Medicine and its practice is advancing in this genre not out of desire but out of fear of being out of compliance.
    I think the EHR systems know and see this- and, rather than lobby for innovation and new measures- they are having to cater to a large populace of providers not ready or desiring that kind of intergration. They just want an electronic system that in ways, is just as haphazardly put together and organized for interface as a random old paper chart.
    Do they say that? No.
    Do they deal with that? Yes.
    Because in this area of population health and patient management- providers are innovating their office with software built for desktop computers.
    Desktop, stationary technology.
    When there are over 5 billion smart phones on earth. FIVE BILLION, they are spending billions perhaps trillions, on a dying breed.
    The moble interfaces are also so restricted and overlooked by the EHR that unless you are checking tomorrows patient schedule it just isnt capiable of preforming.
    I think, the school of thought at the moment has only been to catch up with par. Everyone is running for the layup. Until more hospital systems start looking at mobile intergration with their populace and less with the tower based computing systems- innovation will be stagnant. Because with these hospital systems just trying to stay on par, they are still years behind the technology being deployed and utilized by the public. Their populace of covererage. Their patients.
    Its hard to guide your patients on their path- when your standing so far behind them.
    Health systems need to not just think of making an app- because thats also, only good for them. Silo thoughts and again, just a way of keeping up with the steins. Developing an app was a wonderful idea three four years ago. This now is about the innovation of those products. They need to look ahead and see what existing tools there are for their areas of coverage and leverage those im the community to interface with them. Stop looking for something new- start taking a new look at the things we have.
    96% of men and women age 24-35 would rather go without their deodorant or tooth brush for a day rather than go without their smartphone. It gets steeper when discussing millenials. And these are the population to learn to interact with. Baby boomers? They have their desktop, but they are not in the place for as mich advancement and as mich risk as the you ger populace. We all know if you want to make real strides in population health it needs to be in the lives of the generation having the babies at the moment and get them on the same page as they are with their banking, their shopping, their eating, their exercise- even their dating is phone and mobile based now. Even now Im writing this to you in bed on a lazy sunday morning. Imagine what I could do for myself and my health with access to its data and resources from an intuitive and moble based platform?

    The sooner they intergrate with these generations and demographics- the sooner population health will begin to make the strides we all know it could.
    But I have taken too much of this thread and your time good sir, and for that I will stop soap boxing here on the topic.
    However it did strike a passionate chord in my life.
    As always, thanks for your attention and sharing all this with us again.

    • Thank you for your thoughtful comments, Philip. The EHR was designed to meet regulatory and payer specifications, not for the provider or patient. That explains a lot of what is going on. Another point is that there are many in the EHR space who got in it for a quick buck and had no intention of sticking it out because they had no intentions of investing in the more advanced complexities of the technology vis a vis requirements by regulators. The real challenge is for those who actually use the EHR to rise up and say “We won’t take this anymore!”

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