Standardized Discharge Summary Template Project Mary

Report
Standardized Discharge Summary
Template Project
Mary Shanahan, Senior Manager
Dr John Edmonds, Clinical Director Medical Informatics
CFPC CoI Templates: Slide 1
Faculty/Presenter Disclosure
Faculty: Mary Shanahan, Dr John Edmonds
The Hospital for Sick Children
Relationships with commercial interests:
Nothing to disclose
Agenda
•Background
•Objectives
•Methodology
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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
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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:
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‘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
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‘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
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‘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
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‘Allergies’- should response be just ‘yes/none known’ or list all and any new
•Added fields
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‘Date Completed’
Final Standardized Discharge Summary Template
Revisions 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
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No null responses
•Can section headers be changed?
•Adding additional fields
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Additional fields can be added to the template, maintaining the data element order
Additional documentation can be appended
•Responses should be standardized
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Date format
Gender
Discharged to
•Responses should be in sufficient detail
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‘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: [email protected]

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