Standardized Discharge Summary Template Project

Mary Shanahan, Senior Manager

Dr John Edmonds, Clinical Director Medical Informatics

Faculty/Presenter Disclosure

Faculty: Mary Shanahan, Dr John EdmondsThe Hospital for Sick Children

Relationships with commercial interests:Nothing to disclose

CFPC CoI Templates: Slide 1

Agenda

• Background• Objectives• Methodology

• Project Organization Chart• Initial Design Process• Consultation Process• Project Team Members• Additional Contributors • Feedback Summary• Final Standardized Discharge Summary Template Phase 1• Additional Feedback for Phase 2-Pilot and Implementation

• Conclusion• Phase 2 Contact Information

Background

• Endorsed by the GTA Health Information Collaborative CEOs,

which receives inputs from Healthcare agencies and Healthcare

providers• Aligns with eHealth and LHIN initiatives for sharing

documentation• Hospital Report Manager (Ontario MD)• Discharge Summary exchange projects in other LHINS• Referral and Resource Matching• eHealth Standards Discharge Summary Specification (Nov 2009)

• Discharge Planning Report and Recommendations Submitted on

behalf of the TC LHIN Discharge Planning Steering Group (Aug

2011)• “Discharge planning should be considered as a core and integrated

part of the patient care experience.”• Recommendations for TC LHIN hospitals included the pilot adoption

of minimum standards for discharge summaries

Objectives

• Develop a Standardized Discharge Summary Template• to provide consistency in information sharing for better patient care

and healthcare system efficiency and sustainability• to improve communication and continuity of care as patients transition

between healthcare facilities and providers• consisting of key data elements that can be used by all GTA HIC

organizations and beyond• is grounded in best practices for discharge summary information

• Consult with various stakeholders within and outside GTA HIC

group• Determine challenges and opportunities for consideration in the

implementation phase (Phase 2-sponsored by TC LHIN and

managed by St. Michael’s Hospital)

Project Organization Chart

Methodology-Initial Design Process

Methodology- Consultation Process

Project Team Members

Additional Contributors

Feedback Summary• Definitions/explanations were requested and added for:

• ‘Medical Record Number’• ‘Patient Encounter Type’• ‘Discharge to’• ‘Hospital/Service Name’• ‘Hospital/Service Type’• ‘Adverse Events’• ‘Follow up instructions for patients’

• Moving/combining data elements• ‘Advance Directives’ moved to ‘Course While in Hospital’ and combined with ‘Summary of key results,

investigations, interventions and advance directives’• ‘Discharge Medications’ and ‘Current Medications’ were combined into ‘All Medications at Discharge’

• Rephrasing data elements• ‘Most Responsible Health Care Provider’ -rephrased from ‘Most Responsible Physician’ to account for

Nurse Practitioners• ‘Other Conditions Impacting Hospital Stay’ -previous phrasing of Pre/Post Comorbidities, impacting

Length of Stay was unclear• ‘Follow Up Plan to be implemented by receiving provider’ -previous phrasing of ‘Follow Up Plan for

Provider’ was unclear

• Discussed, but left the same• ‘Allergies’- should response be just ‘yes/none known’ or list all and any new

• Added fields• ‘Date Completed’

Final Standardized Discharge Summary TemplateRevisions from Phase 2 validation

Additional Feedback for Phase 2• Discharge Summary should be completed within 48 hrs• Privacy concerns - does patient need to consent?• Compliance completing the discharge summary report

• No null responses

• Can section headers be changed?• Adding additional fields

• Additional fields can be added to the template, maintaining the data element order• Additional documentation can be appended

• Responses should be standardized• Date format• Gender• Discharged to

• Responses should be in sufficient detail• ‘Follow up for patient’ responses should include contact information for healthcare

facilities that are referenced• ‘Referrals’ responses should include community support agencies, not just healthcare

facilities• ‘Allergies’ – if allergies exist, the response should state what the allergies are and which

ones are new

• For e-discharge, option to select which DI or Lab results should be shared with

the receiving provider

Conclusions

• The process to develop the template engaged GTA healthcare

representatives from all sectors with a high level of participation. • The resulting standardized discharge summary template consists

of key data elements that can be used by all GTA HIC

organizations to improve communication and continuity of care

as patients transition between healthcare facilities and providers.•  It is recommended that a future project pilot the standardized

discharge summary template prior to implementation across the

GTA HIC organizations.

Phase 2 Contact Information

Shez Daya, MHSc, PMP, CPHIMS-CA

Manager, eHealth Program

Toronto Central Local Health Integration Network (LHIN)

425 Bloor Street East, Suite 201

Toronto, ON   M4W 3R4

p: (416) 969-3290

E: shez.daya@lhins.on.ca