1. Here’s some light reading that tells you everything you need to know. Discharge Workflows & Documentation Clinical Informatics Academy September 25 th, 2015 Headed Home?

2. Objectives for Today Identify opportunities in the hospital-to- home discharge process. Discuss & demonstrate strategies to improve and streamline discharge instructions in the EHR. Discuss & demonstrate strategies to improve the medication reconciliation process in the EHR. 1

3. Houston: We Have a Problem ! 2 Interviews with re-admitted patients were conducted in 2013 & 2015*. Most revealing: In interviews of 216 Re-Admitted Patients, 162 or 75% commented negatively on discharge teaching/instructions and/or the discharge process when asked: Was there anything that could have been done differently? *Mae Centeno, DNP,RN,CCNS,ACNS-BC, VP of Chronic Disease Care

4. Major Informatics Themes 3 SchedulingOrganizationEducationMedication “I needed more info about follow-up appointments.” “Too many papers to read. Need more efficient instructions.” “Start teaching earlier.” “Instructions not clear.” “When is my equipment coming?” “Need more info about supplies: O2, etc..” “Too much new information on the day of discharge.” “Written instructions were contradictory.” “When is Home Health coming?” “Overall discharge process is not organized.” “Nurse & doctor provided contradictory instructions.” “Meds were not reconciled.”

5. Can the EHR provide solutions? Scheduling How do we better capture specifics around scheduled follow-up appointments, services and/or equip/supplies? Organization How do we better organize and condense the discharge information? Education/Communication Since the discharging nurse is usually the one to print and review the final instructions with the patient & caregivers, what can we do to facilitate that process? Medication How do we tackle improvements in the Med Rec process? 4

6. How do we get started? 5 First Step: Refine Data Inputs Care Instructions Supply/Equip Info Follow-Up Info Services Info

7. 6 Solution: Discharge Planning Order Set

8. 7 Discharge Planning Order Set Continued

9. 8 Mr. Jones in 321 has a discharge order…

10. How do we better organize/condense? 9 Organize Inputs Deliver to D/C Nurse Facilitate Discharge Discharge Planning Order Set Nursing Discharge Note Discharge Report For Patient

11. Nursing Discharge Note Auto-Population 10

12. Patient Discharge Instructions Report 11

13. Patient Discharge Instructions Report 12

14. Patient Discharge Instructions Report 13

15. Now to Address the Elephant that is Always in the Room…. 14

16. Call to Arms Multiple incidents reported by end-users Due to staggered rollout – was difficult to understand how complex the issue was Two adverse events, root cause analysis showed distinct electronic health record correlations 15

17. Benefits Summary Value Score: High Expected Benefits: Improve patient safety by: ▪ Reducing duplications, omissions, missing medication data and inaccurate data reconciliation forms ▪ Providing patients with a more complete and accurate list of medication instructions at discharge ▪ Reduce medication discrepancies Clinical & Business Processes changed/improved: Standardize and improve workflow for medication reconciliation Improve efficiencies in medication reconciliation process Improve accuracy of patient medication list Improve physician, nursing and pharmacy satisfaction Benefits Summary Value Score: High Expected Benefits: Improve patient safety by: ▪ Reducing duplications, omissions, missing medication data and inaccurate data reconciliation forms ▪ Providing patients with a more complete and accurate list of medication instructions at discharge ▪ Reduce medication discrepancies Clinical & Business Processes changed/improved: Standardize and improve workflow for medication reconciliation Improve efficiencies in medication reconciliation process Improve accuracy of patient medication list Improve physician, nursing and pharmacy satisfaction Bus. Sponsor: Jan Compton Informatics Sponsor: Donna Montgomery ISAC Subcommittee Sponsor: n/a Scope Summary Executive Summary: Medication reconciliation is intended to ensure accurate and consistent communication of a patient’s medication information through transitions of care: Key requirements, deliverables and due-dates: Requirements/Deliverables: Standardization of medication reconciliation process throughout the health system Go-Live: November 2014, Home Medication List revisions – complete March 2015, Admission Reconciliation Enhancements – complete November 2015, Discharge Reconciliation Implementation Project Implementation Note: Workflow recommended will need enhancements in functionality from vendor. Scope Summary Executive Summary: Medication reconciliation is intended to ensure accurate and consistent communication of a patient’s medication information through transitions of care: Key requirements, deliverables and due-dates: Requirements/Deliverables: Standardization of medication reconciliation process throughout the health system Go-Live: November 2014, Home Medication List revisions – complete March 2015, Admission Reconciliation Enhancements – complete November 2015, Discharge Reconciliation Implementation Project Implementation Note: Workflow recommended will need enhancements in functionality from vendor. Performance Summary Strategic Growth: ▪ Attracting and retaining providers and clinicians ▪ Identify and remove barriers in medication reconciliation workflow ▪ Strengthening relationship with patients and fostering feeling of patient centeredness Risk Profile Potential Delays: Resource availability for BIS project components, Implementation timeline for Allscripts 15.1 Deferral: High Operational: High Benefits: High- Patient satisfaction, compliance and safety Dependencies: Resource availability, Implementation timeline for Allscripts 15.1 Performance Summary Strategic Growth: ▪ Attracting and retaining providers and clinicians ▪ Identify and remove barriers in medication reconciliation workflow ▪ Strengthening relationship with patients and fostering feeling of patient centeredness Risk Profile Potential Delays: Resource availability for BIS project components, Implementation timeline for Allscripts 15.1 Deferral: High Operational: High Benefits: High- Patient satisfaction, compliance and safety Dependencies: Resource availability, Implementation timeline for Allscripts 15.1 Financial Impact Costs Associated with the Project: ▪ Cost for obtaining base line data ▪ Cost for participants in workflow improvement meetings ▪ Cost for participants in testing ▪ Cost for Education / training material ▪ Cost for additional FTE(s) at individual facilities depending on recommended process Savings Resulting from the Project: ▪ Reduction in medication error readmissions ▪ Decrease in medication errors ▪ Streamline and enhance medication reconciliation process by reducing duplications by multiple providers/clinicians ▪ Improved efficiencies by providers will allow them to spend more time responding to patient questions, potentially also see more patients, and thereby increase patient satisfaction Financial Impact Costs Associated with the Project: ▪ Cost for obtaining base line data ▪ Cost for participants in workflow improvement meetings ▪ Cost for participants in testing ▪ Cost for Education / training material ▪ Cost for additional FTE(s) at individual facilities depending on recommended process Savings Resulting from the Project: ▪ Reduction in medication error readmissions ▪ Decrease in medication errors ▪ Streamline and enhance medication reconciliation process by reducing duplications by multiple providers/clinicians ▪ Improved efficiencies by providers will allow them to spend more time responding to patient questions, potentially also see more patients, and thereby increase patient satisfaction Medication Reconciliation Primary Benefit: Patient Safety

18. Education/Adoption Standardize education to include optimal workflows to support efficient medication reconciliation process and support wide adoption. Capturing of the patients medication record (list) history. Review and revision of medication list for inpatient admission. Communicate intent of the physician medication orders on admission, transfer and discharge. Enable sharing of appropriate information by both patients and health care professionals. Education/Adoption Standardize education to include optimal workflows to support efficient medication reconciliation process and support wide adoption. Capturing of the patients medication record (list) history. Review and revision of medication list for inpatient admission. Communicate intent of the physician medication orders on admission, transfer and discharge. Enable sharing of appropriate information by both patients and health care professionals. Bus. Sponsor: Jan Compton IS Sponsor: Donna Montgomery ISAC Subcommittee Sponsor: n/a Problem Statement The current environment has multiple barriers to collecting and maintaining an accurate medication reconciliation. This can result in delays in transition of care and duplicated efforts by providers and clinicians. Current medication reconciliation process contains a sub optimal workflow resulting in an overall consumptive use of resources and produces an inaccurate patient medication list. Problem Statement The current environment has multiple barriers to collecting and maintaining an accurate medication reconciliation. This can result in delays in transition of care and duplicated efforts by providers and clinicians. Current medication reconciliation process contains a sub optimal workflow resulting in an overall consumptive use of resources and produces an inaccurate patient medication list. Goal / Aim Statement Improve and streamline the overall process for medication reconciliation through an evaluation of workflows and necessary resources to create clear patient medication discharge instructions. Goal / Aim Statement Improve and streamline the overall process for medication reconciliation through an evaluation of workflows and necessary resources to create clear patient medication discharge instructions. Measures / Metrics Outcome measure –outcome of the process ▪ Decreased readmissions due to medication discrepancy – ask Mae if there is a way to track, are these in Midas? ▪ Complete medication reconciliation Admission/Discharge ▪ Provider / clinician satisfaction survey ▪ Readmission group chart audit – Mae Centeno Process measures – ▪ Home Med Review/Admission Med Rec Dashboard ▪ Discharge Medication Reconciliation Dashboard Balance measures – unintended consequences that may occur ▪ ??? Measures / Metrics Outcome measure –outcome of the process ▪ Decreased readmissions due to medication discrepancy – ask Mae if there is a way to track, are these in Midas? ▪ Complete medication reconciliation Admission/Discharge ▪ Provider / clinician satisfaction survey ▪ Readmission group chart audit – Mae Centeno Process measures – ▪ Home Med Review/Admission Med Rec Dashboard ▪ Discharge Medication Reconciliation Dashboard Balance measures – unintended consequences that may occur ▪ ??? Medication Reconciliation Primary Benefit: Patient Safety

19. So… How bad are we?

20. Mapping the Workflow

26. Demo Fingers crossed, no technical issues…

27. Starts with Discharge Order

28. Guardrails in Place

29. Oh Yeah! That new thing

30. Demo Plan B

46. Houston, We Have a Solution

47. Individual Performance

49. The Final Frontier Can we actually measure a decrease in Adverse Drug Events due to improved Medication Reconciliation? What about correlation to length of stay? Can we show a decrease in readmissions due to improved Medication Reconciliation? 48

50. Questions? 49 Brandi Cannon, MS, PT BrandiC@baylorhealth.edu Jeff Norris BSN, MHA, RN, RN-BC JeffreNo@baylorhealth.edu