Standardized Discharge Summary Template Project Mary Shanahan, Senior Manager Dr John Edmonds, Clinical Director Medical Informatics

Faculty/Presenter Disclosure Faculty: Mary Shanahan, Dr John Edmonds The 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 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 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) E: