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Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams.
Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings.
We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys.
We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness.
Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.
Communication across care teams in hospitals is often disjointed, which can lead to delays in care and adverse outcomes and can negatively affect team dynamics [
Typical approaches for moving discharge to earlier in the day and improving the flow of hospitalized patients rely on one-way communication mechanisms, static documentation in the electronic health record (EHR), and in-person care team huddles or telephone calls, which often take place on the day a patient is expected to be discharged [
Effective use of health information technology (HIT) may introduce a degree of standardization to multidisciplinary rounds and huddles, improve discharge communication workflows, and alleviate delays in discharge [
Tools that enable dissemination of information at both the patient level and team level may provide the greatest utility, as providers and other clinical staff would be able to access information for each individual patient as well as for groups of patients being cared for by a specific team or on a specific floor. Given the success found in the application of HIT in specific domains, such as provider order entry or prescribing of medications [
Addressing the need for a seamless solution to coordinating discharge processes, we developed an innovative tool (the Discharge Today tool) within Epic, the EHR in use at the University of Colorado Hospital, to facilitate communication in real time between hospitalists and other clinical staff regarding discharge readiness and barriers to discharge [
To guide the design of this tool, we applied several frameworks, including the analytic-deliberative model of stakeholder engagement [
Applying the analytic-deliberative model of stakeholder engagement [
To that end, we met with clinical and administrative staff to gain an understanding of their experiences with the discharge process as well as the communication methods and tools currently used to disseminate information on barriers to discharge and readiness for discharge. We conducted workflow analyses with clinical staff directly involved in discharge communication and care of hospitalized patients. Finally, we engaged with patients who experienced discharge from the hospital through one-on-one discussions with patients and their families or caregivers. Stakeholder engagement to inform user-centered design was imperative to ensure that our Discharge Today tool was successfully integrated into existing workflows such that all clinical staff would use this tool with every patient. However, stakeholder engagement was only one aspect of our systematic approach to user-centered design in a clinical setting.
Similar to other types of computer-supported cooperative work technologies that support asynchronous collaboration, such as email, collaborative creation of documents, technologies designed to capture recommendations, repositories for shared information, and particularly workflow applications, the Discharge Today tool is an asynchronous communication tool [
Using the Chokshi and Mann process model for user-centered digital development [
Using the methods described in this model, we were able to identify any fundamental incompatibilities between the EHR and typical clinical workflows, which are potential points of failure for provider-facing innovations. In addition, this model helped guard against overdesign of the tool to accommodate workflows, which can actually inhibit adoption.
As a part of our stakeholder engagement process, we applied a novel strategy, brainwriting premortem [
Following multidisciplinary stakeholder meetings and the brainwriting premortem exercise, we constructed the first of 14 low-fidelity prototypes. These prototypes were presented on paper to stakeholders for feedback and revision. The EHR application analysts building this tool provided guidance regarding the capabilities and limitations of the existing EHR functionality.
Using the final low-fidelity prototype produced, the Discharge Today tool was constructed in the test EHR environment (
Following any changes or additions to the Discharge Today tool, functionality testing took place in the test EHR environment with a secondary validation stage in a shadow EHR environment with real patient data on a set delay. In addition, the end users each tested any revision or addition to the functionality in the test EHR environment prior to moving updates to production. Monitoring of the functionality of the tool occurred via periodic testing of the tool in both the test EHR environment and the production environment to isolate issues with the tool that were not otherwise identified prior to the go-live phase. In addition, feedback was solicited from end users to identify issues that became apparent during clinical work. We approached clinical staff in their workplaces to obtain real-time feedback on the functionality of the tool.
Surveys were conducted following the final month of the pilot phase using Research Electronic Data Capture (REDCap), a secure, web-based application for building and managing web-based surveys and databases [
Final low-fidelity prototype prior to EHR development and the Discharge Today tool (demonstration only, no protected health information).
During the Discover and Define stage of development, applying the analytic-deliberative model, we engaged with 20 different stakeholders in 28 separate meetings across disciplines and settings, including care managers, nurse managers, patients and caregivers, an established, university-based patient advisory panel, and EHR builders and consultants. We also met several times with clinical directors, advanced practice providers, and physicians from departments of hospital medicine, infectious diseases, cardiology, endocrinology, hematology, pulmonary/critical care, and nephrology. Finally, we met multiple times with clinical staff and managers from respiratory therapy, rehabilitation services (specifically occupational, physical, and speech therapy), interventional radiology, pharmacy, glucose management, echocardiography, the heart and vascular team, and dialysis (
Key stakeholders and their engagement activities.
Key stakeholders | Engagement activities |
Patients |
1 Patient Advisory Panel meeting 10 telephone conversations |
Hospital medicine providers |
2 lunch meetings 1 avoidable delay survey 1 user testing session 2 usability and experience surveys |
Nursing staff |
2 meetings 2 usability and experience surveys |
Case management/social work staff |
2 meetings 1 usability and experience survey |
Physical therapy/occupational therapy/speech-language pathology staff |
3 meetings 1 usability and experience survey |
Glucose management team members |
1 meeting |
Pharmacy staff |
2 meetings 1 usability and experience survey |
Respiratory therapy staff |
3 meetings 1 usability and experience survey |
Echocardiography staff |
2 meetings |
Interventional radiology staff |
1 meeting |
Department of Medicine clinical directors |
1 meeting |
Infectious disease staff |
2 meetings |
Cardiology staff |
1 meeting |
Endocrinology staff |
1 meeting |
Hematology staff |
1 meeting |
Pulmonary services staff |
1 meeting |
Renal medicine staff |
1 meeting |
During these meetings, we discussed the stakeholders’ experiences with the discharge process, what went well and what could be improved, and their current workflow related to discharge. We observed clinical staff interacting with the EHR to map how different staff providing care to patients used EHR functionalities and how the Discharge Today tool might best be integrated. Using the information gathered during conversations with and observation of stakeholders, we constructed a user journey to illustrate how the Discharge Today tool might best be integrated with existing workflows and what might be changed (
User journey of the patient discharge workflow. DC Today: Discharge Today; OT: occupational therapy; PT: physical therapy; RT: respiratory therapy; SLP: speech-language pathology.
To work as designed, using guidance provided by the stakeholders involved in our user-centered design process, we developed a framework for our Discharge Today tool, encompassing the following functions and operational processes. First, the tool must populate a list of patients with information from designated data sources and display the results on a user interface dashboard for provider access. Second, the tool must be accessible from the customizable patient worklist available in the provider workflow whenever a provider logs into the EHR. Third, the discharge readiness status for each patient on a provider’s list must be displayed with color-coding (green if the patient is a definite discharge with a discharge order, yellow if the patient is a definite discharge without a discharge order, orange if the patient is a possible discharge this day, blue if the patient could go home tomorrow, red if the patient is not going home this day, and gray if the patient is expected to go home in the next 24 to 48 hours). Fourth, data collected from primary team providers each morning via the Discharge Today tool must be pushed automatically through three different processes that are integrated seamlessly with existing clinical workflows: the EHR patient worklists via the Discharge Today follow-up column, the Care Progression report, and an auto-generated page. Finally, through a feedback mechanism implemented such that when staff from ancillary departments such as respiratory therapy (RT), physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) document patient care in the EHR using their standard workflow, the primary team provider who originally reported a requirement from these ancillary departments must be alerted that something has changed, creating a feedback loop within the EHR. To alert providers using the Discharge Today tool, an icon indicating new information is populated in the Discharge Today tool column displayed in the provider’s list. Combining this functionality creates a tool that enables real-time communication among care team members via the EHR.
All data collected by the Discharge Today tool are stored in the transactional database of the EHR at the level of the patient hospital encounter. This supports real-time use, functional processes, and dashboard population. The tool populates a list of patients managed by individual providers with patient attributes, encounter attributes, provider attributes, and discharge readiness status, timing, and barriers into a user interface dashboard. Providers interact with their patient list in the dashboard and make item entries for each patient from structured category lists (
Discharge Today data elements and sources in the electronic health record.
Data element | Data source/location |
Patient attributes | Patient record |
Encounter attributes | Hospital encounter record |
Provider attributes | Provider record |
Discharge probability categories | Transactional database tables |
User interface highlight colors | Code extension |
Discharge timing categories | Transactional database tables |
Discharge barriers | Transactional database tables/alert criteria |
Discharge follow-up comments | Transactional database tables |
During the Develop and Deliver phase, from March 5 to July 31, 2019, we conducted iterative development, testing, and optimization of the Discharge Today tool while in use by Hospital Medicine advanced practice providers and physicians. During this phase, stakeholders requested 46 modifications, with 85% of these requests occurring in the first two months of the pilot study. Of the 46 modifications, 11 (24%) were set aside due to existing limitations in EHR functionality, and 10 (22%) were considered to have insufficient utility or potential for overdesign and were thus not pursued. A total of 25/46 modifications (54%) were successfully executed, and 3 of the 25 modifications (12%) were fully implemented after the end of the pilot period (
Modifications to the Discharge Today tool (N=25).
Date requested (2019) | Request | Date fully modified (2019) |
March 7 | Rename columns to help with clarity when providers are wrenching them in | March 8 |
March 11 | If a provider reselects “possible,” “definite,” or “no,” reset the branching logic | March 14 |
March 17 | PTa/OTb/SLPc pages are sent out when selected, with lockout if more than one page is selected within 12 hours | March 8 |
April 1 | Update names of columns to be less confusing for wrenching in or display in larger patient lists | April 8 |
March 5 | Add Transportation as a barrier | April 12 |
March 6 | Add PICCd Line Placement as a barrier | April 12 |
March 8 | Add a way to indicate future discharge (ie, in 24-48 hours) | April 12 |
March 12 | Add DMEe as a barrier | April 12 |
March 12 | Update RTf barrier to Home O2 | April 12 |
March 12 | Update the Social Work barrier to Social Work/Care Management | April 12 |
March 12 | Add “Other consultant not listed” as a barrier | April 12 |
March 12 | Update pager system to allow a page once every 12 hours | April 12 |
April 19 | Combine PT and OT pager numbers | April 26 |
April 24 | Indicate in the page set to PT/OT which discharge selection was made (“Possible” or “Definite”) | April 26 |
March 11 | Reset column after 3 days | May 23 |
March 11 | Automatically update to definite (green) when a discharge order is placed | May 23 |
April 11 | Change the order of the barrier selections | May 23 |
April 12 | New column to display barrier selections from the Discharge Today Primary column | May 23 |
April 12 | Make the “In 24-48 hours” selection gray in color | May 27 |
March 5 | Develop a feedback loop | June 24 |
April 26 | Add Test Results (Laboratory, Radiology) as a barrier | June 27 |
June 14 | Add Wound Care as a barrier | June 27 |
May 7 | Add fields to capture more information about PT/OT barriers | July 30 |
July 2 | Change “No” to “>48 hours” | September 27 |
March 15 | Add option to select for anticipated discharge tomorrow | December 3 |
aPT: physical therapy.
bOT: occupational therapy.
cSLP: speech-language pathology.
dPICC: peripherally inserted central catheter.
eDME: durable medical equipment.
fRT: respiratory therapy.
We found that most providers who responded to the usability and experience survey (21/24, 88%) reported that the tool either shortened or did not change the amount of time required to complete the discharge workflow. Of the nursing, care management, and other clinical staff surveyed who reported using the Discharge Today tool during the pilot study (34/67, 51%), all felt that the tool either shortened or did not change the amount of time required to complete their workflows. In addition, a majority of ancillary staff who completed the survey reported that they believed that hospitalists were updating the discharge information (26/34, 77%), that the information was accurate (22/34, 65%), and that the information was helpful (32/34, 94%). These data suggest that the Discharge Today tool was successfully adopted by providers and other clinical staff (
Provider (n=24) and clinical staff (n=67) responses to the survey on usability and experience of the Discharge Today tool following the pilot implementation period.
Question | Response, n (%) | |||
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Entered/updated discharge information in patient list column | 21 (88) | |
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Viewed discharge information in patient list column | 13 (54) | |
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Viewed discharge information in the care progression report | 3 (13) | |
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Determine order of rounds, prioritizing early discharges | 1 (4) | |
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0%-25% | 0 (0) | |
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26%-50% | 5 (21) | |
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51%-75% | 3 (13) | |
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76%-100% | 16 (67) | |
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Beginning of shift | 21 (88) | |
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Middle of shift | 5 (21) | |
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End of shift | 6 (25) | |
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Saved time | 6 (25) | |
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Added time | 3 (13) | |
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Did not change | 15 (63) | |
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Yes | 34 (51) | |
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No | 33 (49) | |
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Viewed discharge information in my clinical workflow | 31 (91) | |
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Contacted hospitalist who entered information in Epic | 5 (15) | |
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Viewed discharge information in the care progression report | 14 (41) | |
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Do you feel hospitalists are completing and updating the discharge information? | 26 (77) | ||
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Did you find the information accurate? | 22 (65) | ||
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Did you find the information helpful? | 32 (94) | ||
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|||
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Saved time | 21 (62) | |
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Added time | 0 (0) | |
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Did not change | 13 (38) | |
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Do you find the tool helpful? | 31 (91) | ||
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Discharge information not completed by hospitalists | 6 (18) | |
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Information not updated/accurate | 7 (21) | |
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Lack of time | 5 (15) | |
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Lack of knowledge | 20 (61) | |
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Forgot/overlooked | 3 (9) | |
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Chose not to | 1 (3) | |
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Other | 4 (12) |
We also collected qualitative usability and experience data from hospital medicine providers and clinical staff following the pilot implementation period using open-ended questions in the REDCap survey. Themes were derived from responses provided to five open-ended questions included in the survey. Free text responses were coded, and a synthesis of the results emerging from the responses to each of the open-ended questions was summarized (
Responses were categorized into five themes, namely efficiency, integration into workflow, redundancies avoided, expedited communication, and patient-centered outcomes. The data provided both positive feedback and opportunities for improvement.
Qualitative usability and experience data from hospitalists and other clinical staff following pilot implementation of the Discharge Today tool.
Theme | Quotes | |
|
Positive feedback | Opportunities for improvement |
Efficiency | “Noticed quick responses from PT/OT for evaluation which expedited discharge.” |
“Not all teams are utilizing the tool yet.” |
Integration into workflow | “Well integrated into my existing workflow.” | “Sometimes the options available to explain what is holding up a discharge does not apply…would be nice to have an “other” comment box.” |
Avoidance of redundancy | “In theory, it should avoid redundancies and emphasize the hold up to discharges…If nurses know we are consistently updating this it would help eliminate unnecessary pages.” | “Other services/staff learning to utilize it in their workflows.” |
Expedited communication | “It is nice to be able to state what would be potentially holding up the discharge and not have to call those services/departments directly.” | “A little more feedback about what is happening as we click these things (like a little small font blurb).” |
Patient-centered outcomes | “Per the DC tool knew [the patient was] going to be going home in the next day or two. I was able to decide on a DC plan and send the prescriptions to the pharmacy for fill. Low [ |
“Would it be possible that a checklist could be given to the patient? Allowing patient to follow the process…an opportunity to ask questions?” |
The important findings of this work are (1) providers, hospital clinical staff, and patients are willing to serve as stakeholders to help guide the user-centered design of an EHR-based tool and (2) stakeholder engagement during preimplementation, throughout implementation, and into postimplementation results in positive feedback and substantial adoption by clinical staff.
We applied communication theory to the design of this tool with the intent of fostering interdisciplinary discharge communication and teamwork. Communication across care teams and improved interdisciplinary care has been recognized as an important factor for high-quality patient-centered care and for high-functioning teams. Studies have shown that when care teams communicate better, efficiency outcomes are improved [
Studies exploring the use of the EHR for discharge planning have been limited to static electronic reports constructed from EHR data elements, including barriers to discharge documented at admission, care management data, and discharge criteria [
Tyler et al [
Although common quality improvement tactics, such as identifying champions, Plan-Do-Study-Act cycles, and process mapping, are valuable tools, developing and implementing HIT innovations necessitates frameworks and methods that are specifically designed for HIT. To engage hospitalists, nurses, other clinical staff, patients, families and caregivers, and hospital leadership, we met with 20 different stakeholder groups to obtain feedback about the design and functionality of the tool. Following this engagement process, we made improvements, implemented a pilot tool, and assessed discharge processes and both provider and clinical staff experience with the tool. To guide the development and implementation of our pilot Discharge Today tool, we chose to apply the analytic-deliberative model of stakeholder engagement [
Our approach to stakeholder engagement and user-centered design had a number of strengths. We deliberately, proactively applied established frameworks to guide both our stakeholder engagement process and the process of designing our tool. In addition, we leveraged existing functionality in our EHR to create an innovative discharge communication tool based on a design framework developed in collaboration with our stakeholders. Finally, this discharge communication tool facilitates real-time communication across hospital clinical staff, reducing reliance on static communication tools or interruptions to clinical care.
Our approach had a few limitations. We were unable to identify stakeholders in every clinical area of the hospital with whom communication about patient discharge readiness or barriers may occur. In addition, limitations to functionality of the EHR at the time of the development of this tool restricted the development of feedback loops to discharge barriers related to physical therapy, occupational therapy, speech therapy, and respiratory therapy rather than across all clinical areas. We continue to work with hospital leadership to fully integrate the Discharge Today tool with other initiatives implemented to improve discharge processes, improve patient flow, and alleviate capacity problems. Finally, as this tool expands in scale, future work will begin to assess how this type of tool (and future modifications thereof) affects quality measures such as patient experience, teamwork, and potentially readmissions.
By using a deliberate and collaborative stakeholder engagement process, we obtained commitments from numerous key stakeholders to participate in the design and testing of our EHR discharge readiness tool. The tool has been implemented for clinical use, and we have conducted an extensive evaluation of the implementation and effectiveness of the tool from a multistakeholder perspective. Survey data collected from Hospital Medicine providers and ancillary clinical staff suggest that the tool has been successfully adopted by clinical staff.
electronic health record
health information technology
occupational therapy
physical therapy
Research Electronic Data Capture
respiratory therapy
speech-language pathology
The authors report funding from the Data Science to Patient Value program at the University of Colorado, Anschutz Medical Campus.
None declared.