We must place a higher value on discharge paperwork

The discharge process has now been recognized as one of the most crucial points at which the actions of doctors and hospitals can have a huge impact on immediate health outcomes for our patients. At a time when 30-day readmission rates are still touching almost 20% for Medicare patients, there is an increasingly urgent need to focus on this transition of care point. Discharging a patient is, by its very nature, a risky process. Patients are typically still not at their baseline, and their recovery hangs in the balance. As the main physician, the role of hospital doctors is pivotal in making discharges as flawless as possible.

Let’s go through how the typical hospital discharge works in the world of medicine. The doctor will see the patient and make the decision that they are well enough to leave the hospital. These discharge plans will often only be made clear at the last moment. The nurse may be taken by surprise as the doctor pops their head through another patient room to inform her of the great news: “Mr. Adams can go home, I’m discharging him.”

After a brisk discharge summary and the completion of the paperwork, the patient and their family will get a piece of paper given to them by their nurse. If it’s not written in ineligible writing (using medical jargon that most doctors’ own parents wouldn’t even understand) on a thin sheet of paper, they will get a printed piece of paper where the doctor has entered the information on a computer. In either case, the whole piece of paper will be less than appealing in appearance. It will contain the patient’s discharge diagnosis, medications (frequently with changes from the admission medications), and follow-up instructions.

This is one aspect of the discharge that I’ve always wondered about, and has pretty much been overlooked in every hospital I’ve ever worked in: The design of the discharge paperwork.

What am I talking about? Well let’s suppose you are asked to follow through on some very important instructions, would you be more likely to follow them if they were presented to you on a tatty piece of paper or well-presented in a more beautiful and eye-catching way?

There is simply no way that most patients can understand what’s given to them. It’s strange that we don’t pay more attention to this. When we hand patients, especially the elderly, papers with a dull and dreary design and small unattractive fonts — they are considerably less likely to be able to read the information. In fact, the current printed paperwork most hospitals give to patients often looks like it comes from the typewriter age!

More importantly what message does it give about the hospital and our profession? As a further sign of how little thought we put into the paperwork, it’s fairly common everywhere for doctors to use abbreviations such as “CHF with low EF” (congestive heart failure with low ejection fraction) or “COPD with PNA” (chronic obstructive pulmonary disease with pneumonia). I mean, who is the paperwork really for? It’s no wonder that the discharge process can be haphazard and risky when the piece of paper we hand our patients is so difficult to understand.

This is a classic example of where we get one simple but vital aspect in a communication chain wrong. Although most hospitals now have printed instructions, thanks in part to fulfilling “Meaningful Use requirements” (an understandably important goal for hospitals) — things still need to be taken to the next level. Remember, the idea of certain parts of meaningful use is to better communicate medication changes to patients. When the printout is suboptimal, we are therefore missing a final link in the communication chain. It might contain the most valuable insights imaginable, but without people wanting to read it, it’s quite worthless.

What do we need? Hospitals should design beautiful, colorful, easy-to-read discharge instructions. These should be printed out on card. Short and simple. No complicated medical terminology or abbreviations. Whatever patients do with it afterwards; read it, put it on their fridge, or even throw it away — is up to them, but at least we have given them something that they are more likely to read in the first place. Hospitals need to get patient and staff feedback on their current paper format and then utilize their design department to improve on what they have. Other marketing advice might also be needed. A small investment really for the enormous potential benefits.

We must place higher value on the discharge paperwork. It’s arguably one of the most crucial things we do for our patients during their hospital stay.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

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  • Patient Kit

    Aside from a font size that most older eyes can read, I don’t care about making discharge papers prettier to look at. I’m all about the content and clear communication. Let’s concentrate alll efforts on that. Make it easily readable, concise but complete and clear (clear being the opposite of vague and confusing and cryptic). That’s all I ask. No need for fancy fonts and more expensive colorful paper.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I have a question: Why are we discharging people that “are typically still not at their baseline, and their recovery hangs in the balance”? Would it kill us to let them stay in the hospital a few more days, until they are ready to be discharged? And do we think that handing them an infographic before we kick them out is a good substitute for proper care?

    • guest

      Well, we have to discharge them before they are ready for discharge because that’s what Medicare says to do. The eye-catching infographic is intended to keep them from being readmitted right away, which they are inclined to do since they have been discharged prematurely.

      If we make the infographic eye-catching enough, patients and their families might not even notice that they are being expected to provide for themselves and their family members the nursing care at home post-discharge that used to be provided in the hospital towards the end of the hospitalization.

      Doesn’t it all make sense now?

      • Patient Kit

        So, please correct me if I’m getting this wrong: Medicare (and insurance companies) pressures doctors to discharge patients asap, prematurely, before they are medically ready to go home. And then they penalize you if your readmission rates go up? On the other hand, with more and more surgery being done on an outpatient basis, they can’t penalize you for readmitting patients who were never admitted in the first place……Can they?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Oh yeah… it’s all about value-based care…. :-)

      • Arby

        I am not intending to weigh in on the point where the insurance companies/administration push physicians to get a patient discharged before it is safe to do so, because I do not know at what point that is as I am not a physician or to speculate on how physicians walk that fine line.

        However, I will say as far as I know, it is in a patients best interest to get out of the nosocomial soup that is a hospital as soon as possible, not to mention away from the stress, lack of sleep, lack of privacy, etc. that you endure there.

        So, if you are sending a patient home, even from an outpatient procedure, at the very least provide them with instructions that are legible and useful, and yes, design does come into play for this. Right now, all I have is the internet [which is fine, but then you have to dig through every alternative medicine woo idea and every horror story to find pertinent information] since every discharge instruction I’ve received in at least the last 15 years has been useless.

    • Dr. Drake Ramoray

      In residency the discharge condition was sometimes referred to as the new baseline.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        moving goal posts… and now moving baselines too? :-)

        • Dr. Drake Ramoray

          With the release of physician payment data by Medicare expect to see a lot more shenanigans. (I’m proud of myself for using the word shenanigans in a post before 7 AM). Our hospitalists are already discouraged from using the discharge diagnosis of “heart failure” because of the penalties for readmission for this condition.

          Mostly though as a result of the coming wave as I have posted before doctors will just pad their practices with uncomplicated patients and move out of underserved poor areas where there are more complications in the first place (change fields or sports altogether) or just stop treating certain diagnoses like diabetes.

          As expected the title is “Medicare pays doctors Millions…..”

          http://www.huffingtonpost.com/2014/04/09/medicare-paid-doctors-millions-database-shows_n_5115393.html

          Lifted from this.

          “If the data indicated a particular doctor’s diabetic patients were having unusually high rates of complications, that doctor might face questions.

          Such oversight would probably accelerate trends toward large medical groups and doctors working as employees instead of in small practices.”

          Compare my fairly rural practice with higher rates of poverty, poor education, and baseline increased complication rate to practices in the affluent suburbs with a healthier populations. No thanks. Even if I stayed, why would I keep a continually non-compliant diabetic patient in my practice who is just going to get me audited?

          Direct pay no diabetes within the next 1-2 years. As I have posted vigorously in the past there are no quality measures as of yet for thyroid.

  • NewMexicoRam

    How about just making a good note, the way you would want it if someone else were making one for you to read later? Concise as possible, yet detailed enough to know exactly what the provider was thinking at the time of discharge.

  • T H

    From the ED perspective, at least 25% of the materials we supply to discharged patients remains in the room after the patient has left, up to and including follow-up appointment slips, prescriptions, and lists of free and reduced price clinics if they do not have a family doc.

    No good purpose indeed.

  • guest

    Other than that, it’s a fine idea…

  • medicontheedge

    As both a staff member and as a user of our services, I can say our hospital begins “discharge planning” early on in the admission, often pre-op. We are very aware of re-admissions punishments, drug reconciliations, awareness of safety and domestic violence, elder and child abuse, etc etc, and all the social issues that have glommed onto delivering medical care. Our discharge instructions are clear, written in everyday language at the 4th grade level, are reviewed by the discharging RN with the patient and family/SO’s, who are encouraged to ask for clarification if they need more info or are confused. For patients discharged to “skilled” nursing facilities ans assisted living residences, a copy of the patients chart, a regulated form is filled ut, and a verbal report is called to the accepting facility.
    Great, right? WRONG. It is often a complete waste of time. Some patients and families listen, ask questions, etc. Many DON’T. Over and over we see people come back over and over because they just did not follow the directions, take the meds, followup with their PMD, etc..We have come to expect our healthcare delivery like fast food: easy, quick, and without effort on our part.