Workflow Models of Hospital Discharge Communications

R Summers’, A. P. Cloke’, D. Nurse3 and J. D. S. Kay3

1. MIM Centre, City University, London, UK. 2. Centre for Radiographic and Medical Studies, Royal Military College of Science,

Shrivenham, and UK. 3. Medical Informatics Unit, Dept. Clinical Biochemistry, Oxford Radcliffe Hospital,

Oxford, UK.

Abstract: The discharge communications between the John Radcliffe Hospital, Oxford, and its referring General Practitioner’s (GP’s) in the community are investigated. These documents are known by a variety of names. To prevent confusion two descriptors are introduced: the immediate discharge document (IDD), and full discharge document (FDD). From a survey of different Hospital Units four patterns of workflow are identified. A common IDD that meets the majority of the needs of the GP is suggested, this will also allow for a distributed computerized solution to improve workflow processes. Initial results do indicate an increase in efficiency and effectiveness of hospital discharge communications due to the technocentric intervention.

Keywords: workflow; discharge letters; hospital communications.

1. Introduction

On discharge from hospital in the United Kingdom (UK), written communications are normally passed to the patient’s General Practitioner (GP) working in the community. These are known by a variety of names, to avoid confusion the following definitions apply. The Immediate Discharge Document (IDD) is a provisional document, ofken completed by a junior doctor, issued on the day of discharge either by mailing the GP directly or handing it to the patient for onward transmission. It is used to communicate essential information about a patient’s hospital treatment and any drugs issued to the patient on their discharge. The Full Discharge Document (FDD) is a more definitive account of the patient’s treatment, and is usually completed by a senior physician. This document is sent to the GP a few days or weeks after the patient’s discharge from hospital.

The content and format of these communications varies widely between hospitals and departments within hospitals. In some departments the IDD forms the only communication between the hospital and the GP, while in others it is always followed up by the FDD at a later date.

Some departments only issue a FDD when the patient’s continued care presents existing or anticipated complications.

There is a considerable literature that addresses the issues involved in hospital discharge communications. For example, Harding [l] indicates that GP’s consider it important for hospital discharge communications to be received within fourteen days of the patient leaving hospital. Clements [2] shows that in many instances the content of the communication is lacking in information that they considered essential for good patient management. The report by Jones and Hagger [3] indicates that wider distribution of information to other healthcare professionals and social workers might have some benefit for primary patient care.

Introduction of appropriate technology may provide a solution to many of the issues involved and problems confronted in the production of hospital discharge communications. However, before any technological solution can be assessed, it is important to fully understand and appreciate the work processes involved (i.e. workflow) in the delivery of effective communication between hospital and GP.

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2. Worktlow Model

It was thought that it might be possible to identify data that are common to all discharge communications. To test this hypothesis, structured interviews were conducted in four departments of the Oxford Radcliffe Hospital, Oxford: Acute General Medicine, the Children’s Clinical Centre, Clinical Haematology and General Surgery. On the basis of these interviews, discharge communications can be classified as belonging to one of four possibiie workflow pathways, as shown in Table 1. Pa thwiu

Patienls in this pathway require no hospitd discharge communication. The patients all form acute admissions to hospital for observation only, rather than have a planned course of medical or surgical treatment. They are usually discharged on the day following their admission, spending less than twenty-four hours in hospital. The observations have produced no significant positive indicalions of a clinical condition in need of treatment.

Pathwad

In this pathway only a single discharge communication, the IDD, is generated. Usually this is hand-written, though some deparbments made use of computer-based technalogy to generate the IDD, in the form of a simple patient database combined with a word-processed template letter.

P a t h w u

The majority of patients discharged can be classified as belonging to this workflow pathway. The junior physician who completes the IDD makes the decision that a FDD is required. With a single exception the same workflow is followed in all the clinical specialties visited. A senior physician dictates the FDD, and

passedl back for approval and signature. The secretary then dispatches the FDD using the normal postal service.

after transcription by the team secretary, is

Each department stated that they were able to complete the FDD within the time period given in hospital guidelines. On average, the time taken from dispatch to delivery at the GP surgery is three days. A typical FDD reaches the GP Surgery twenty-four days after the patient’s discharge

Pathway 4

All the patients in this pathway require support from health care or social service agencies on their discharge from hospital. The decision to involve social and welfare services depends upon the ongoing assessments of the patient’s ability to function as an independent individual on discharge, and will vary greatly with the patient’s age, clinical condition and treatment. These assessments are performed by a health care team comprising the physician, the patient’s personal nurse, other hospital-based health care personnel (as required), and social care professionals. The patient’s relatives and lay groups with interests in specific medical conditions may also be involved in planning the support required. Those involved in the primary support process are present or represented at meetings held to plan the care of the individual patient.

Although many of the patients are discharged to their own homes, or those of relatives, some are transferred to full-time residential or nursing care facilities. This may involve sending the IDD and FDD to more than one GP, that is, to the referring GP and to the GP whose Surgery covers the patient’s place of abode upon hospital discharge. In addition, discharge letters are sent by other hospital-based health care and social care professionals to their opposite numbers in the primary care sector.

The format of these communications, which may be hand-written or word- processed, varies depending upon their originator and recipient. Normally, the patient is not discharged or transferred from hospital until the necessary support is arranged, and the majority of the communications are dispatched by the

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Pathway Type of Communication 1 Discharge communication not required 2 IDD only 3 IDD and FDD 4 IDD and FDD plus letters to other

Primary Sector personnel I

normal postal service prior to the patient leaving the hospital.

% of All Discharges 10 1s 58 14

4. The Impact of IT on Workflow

The practice of relying on the patient or one of their relatives to deliver the IDD to the GP can result in a long delay before its receipt, or even its loss. Using the postal services for the transmission of the FDD takes on average three working days before it reaches the GP. The impact of using computer aided communication has two benefits: the IDD (especially) and FDD are ready for dispatch much earlier than their hand-written counterparts; and once ready, their dispatch is instantaneous. Also, if the GP has a receiving computer- based system that is able to communicate using Electronic Data Interchange (EDI) then the discharge communication can be electronically stored directly in the patient records on the GP’s computer system. The information infrastructure required for this solution is discussed below.

There are also a number of other IT solutions that vary in their complexity from using facsimile (fax) machines and electronic mail (e-mail) through to ED1 messaging systems. A previous study has shown that all of the GP Practices in the Oxford area have facilities to send and receive fax messages [4]. This technology has the advantage that it will process both hand-written and word-processed documents, although hand-written documents can be illegible. The medium in which the document is sent and received can either be in paper or electronic form, depending upon type of hardware used. A computer that has fax functionality as an integrated component would enable verification of the caller’s telephone

number before the transmission of the faxed document, increasing the security of transmission of the confidential information. Computer-based solutions can also provide a facility to sort and store the documents to be sent by the descriptor ‘GP Practice’. With suitable sofhvare, this would allow the GP to specify times that they wished to receive the documents, allowing the GP to arrange their receipt at a time which suits their working practice, without making a significant impact on the working practices in the hospital.

For electronic communication of the IDD and FDD, an information infrastructure that traditionally has a centralized Hospital Information System (HIS) acting as core provider is required. Whereas there is a UK Government-led initiative to ensure that there is a computer-based information system in every GP Practice, hospitals have built up a suite of legacy systems. Hospital personnel become committed to their use making the provision of an evolutionary pathway to an integrated health care information system difficult to find. One way around this confusion is to use a Web-based solution: the development of a hospital Intranet using hypertext documents may eliminate the need for a central HIS [4]. The problems associated with data security still remain, but security is a problem common to any type of network system, and Intranets have been used successfully in the commercial and business sectors for some time without reports of their security being breached. Such a solution would also benefit workflow processes because this virtual document can be accessed wherever and whenever the junior physician wants to continue with the production of the IDD. Arguably, the FDD workflow process will

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also ba affected in a beneficial way, as the exchange of documents between senior physician and team secretary can be achieved both instantaneously and at a distance.

It is difficult to quantify the financial cost of the current systems in use at the Oxford Radcliffe Hospital. A study [5] that was limited to a single clinical specialty, pediatrics, could be used as a guide, as the hospital discharge documentation is very similar to the current practice for the majority of patients in Oxford. The Paediatric Departtment produces a hand- written IDD and a word-processed FDD for all patients. Both are dispatched by the conventional postal system to the patient’s GP, and an additional copy of the IDD is also h,mded to the patient’s parents to pass to their GP by hand. The department produces approximately 5,300 discharge documents per year, each one taking just under 18 minutes to produce. The annual cost of producing these discharge letters is appro:rimately 215,000. There is a proposal to change the system to one making use of a networked PC and fax transmission; this would reduce the workflow process by eight minutes; giving an annual saving of €3,000. Other benefits disclosed by the author show a reduction in the time taken to get the FDD to the GP and a reduction in the number of requests from GPs for further information. There have also been fewer complaints from junior physicians and nursing staff about the task of producing discharge documentation, indicating a greater degree of staff satisfaction with the process.

5. Discussion

The discharge process follows the same pattern in all departments studied and is initiated by the clinical team responsible for care provision. Although the discharge process can be split into four pathways, there remains a considerable degree of variation in the structure of the communication itself. It is appreciated that some degree of variation is necessary as, for example, documentation generated by surgical and medical wards will report different events. The use of a standard

form ensures that data, such as the patient’s name, home address, hospital ward and details of the treating physician, are always present in the IDD.

Given this background the following eight factors were identified as those required to gauge the critical success of the workflow model for hospital discharge communications:

the approximate number of IDD’s produced in each Hospital Unit per week; identification of the person who initiates the discharge communication and the process by which they are completed; the amount of time taken to process a ‘typical’ discharge communication; the data content of the communication; what communication is sent to whom, and when?; the method of transmitting the information to the GP and approximate transit time for a ‘typical’ communication; identification of other healthcare and support workers routinely informed of a patient’s needs on discharge; and, the method by which GPs are informed of ‘to take out’ (TTO) medications prescribed for the patient.

With the hand-written IDD, poor quality of the third copy that is retained in the patient’s notes can give rise to problems when producing the FDD. It is also not unknown for the original IDD to become lost or damaged in some way. This can be reproduced very easily using the stored electronic copy that remains available on the computer, this is not the case with the hand-written IDD.

6. Conclusion

There is a common workflow pattern within the clinical specialties surveyed. The need for an improved method for delivering discharge communications from the hospital to the GP is indicated. A technological solution, using a hospital Intranet, is available using the existing

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information infrastructure. The use of this technology also offers an opportunity for financial cost savings.

Acknowledgements

The authors wish to the thank colleagues in the four clinical departments investigated, who gave up their valuable time and provided a much needed clinical perspective that was insightful for the development of suggested technological solutions.

References

[l] J. Harding. Study of discharge communications from doctors to an inner London General Practice. J. Roy. Coll. General Practitioners. Vol. 37, pp.494- 495,1987.

[2] D. Clements. An improved ‘interim discharge letter’: a successful outcome from audit. J. Roy. Coll. Physicians. Vol. 26 (2), pp. 169-171, 1992.

[3] A. Jones and D. Hagger. Transferring and sharing information from electronic patient records. In: Proc. Exchanging Health Care Information 96. Weybridge: BJHC Ltd. pp. 108-112, 1996.

[4] D. Nurse, P. Phillips, J. D. S. Kay and S. Ruddell. Managing clinical documents. Case study: Oxford Radcliffe NHS Trust. In: Proc. Exchanging Health Care Information 96. Weybridge: BJHC Ltd. pp. 102-107, 1996.

[ 5 ] C. Cramp. Process improvement of discharge summaries - a project in a paediatric department. Clinician in Management. Vol. 5 (6), pp. 4-7, 1997.

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